Federal Free Printable 2016 Form 1099-SA for 2017 Federal Distributions From an HSA, Archer MSA, or Medicare Advantage MSA

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Distributions From an HSA, Archer MSA, or Medicare Advantage MSA
2016 Form 1099-SA

9494 VOID CORRECTED TRUSTEE'S/PAYER'S name, street address, city or town, state or province, country, ZIP or foreign postal code, and telephone number OMB No. 1545-1517 2016 Form 1099-SA PAYER'S federal identification number RECIPIENT'S identification number RECIPIENT'S name 1 Gross distribution 2 Earnings on excess cont. $ $ 3 Distribution code 4 FMV on date of death $ Street address (including apt. no.) City or town, state or province, country, and ZIP or foreign postal code Account number (see instructions) Distributions From an HSA, Archer MSA, or Medicare Advantage MSA 5 HSA Archer MSA MA MSA Copy A For Internal Revenue Service Center File with Form 1096. For Privacy Act and Paperwork Reduction Act Notice, see the 2016 General Instructions for Certain Information Returns. 1099-SA Cat. No. 38471D www.irs.gov/form1099sa Department of the Treasury - Internal Revenue Service Do Not Cut or Separate Forms on This Page — Do Not Cut or Separate Forms on This Page Form CORRECTED (if checked) TRUSTEE'S/PAYER'S name, street address, city or town, state or province, country, ZIP or foreign postal code, and telephone number OMB No. 1545-1517 2016 Form 1099-SA Distributions From an HSA, Archer MSA, or Medicare Advantage MSA 1 Gross distribution 2 Earnings on excess cont. $ $ RECIPIENT'S name 3 Distribution code 4 FMV on date of death Street address (including apt. no.) 5 HSA PAYER'S federal identification number RECIPIENT'S identification number Copy B For Recipient $ City or town, state or province, country, and ZIP or foreign postal code Archer MSA MA MSA This information is being furnished to the Internal Revenue Service. Account number (see instructions) Form 1099-SA (keep for your records) www.irs.gov/form1099sa Department of the Treasury - Internal Revenue Service Instructions for Recipient Distributions from a health savings account (HSA), Archer medical savings account (MSA), or Medicare Advantage (MA) MSA are reported to you on Form 1099-SA. File Form 8853 or Form 8889 with your Form 1040 to report a distribution from these accounts even if the distribution is not taxable. The payer is not required to compute the taxable amount of any distribution. An HSA or Archer MSA distribution is not taxable if you used it to pay qualified medical expenses of the account holder or eligible family member or you rolled it over. An HSA may be rolled over to another HSA; an Archer MSA may be rolled over to another Archer MSA or an HSA. An MA MSA is not taxable if you used it to pay qualified medical expenses of the account holder only. If you did not use the distribution from an HSA, Archer MSA, or MA MSA to pay for qualified medical expenses, or in the case of an HSA or Archer MSA, you did not roll it over, you must include the distribution in your income (see Form 8853 or Form 8889). Also, you may owe a penalty. You may repay a mistaken distribution from an HSA no later than April 15 following the first year you knew or should have known the distribution was a mistake, providing the trustee allows the repayment. For more information, see the Instructions for Form 8853 and the Instructions for Form 8889. Also see Pub. 969. Spouse beneficiary. If you inherited an Archer MSA or MA MSA because of the death of your spouse, special rules apply. See the Instructions for Form 8853. If you inherited an HSA because of the death of your spouse, see the Instructions for Form 8889. Estate beneficiary. If the HSA, Archer MSA, or MA MSA account holder dies and the estate is the beneficiary, the fair market value (FMV) of the account on the date of death is includible in the account holder’s gross income. Report the amount on the account holder’s final income tax return. Nonspouse beneficiary. If you inherited the HSA, Archer MSA, or MA MSA from someone who was not your spouse, you must report as income on your tax return the FMV of the account as of the date of death. Report the FMV on your tax return for the year the account owner died even if you received the distribution from the account in a later year. See the Instructions for Form 8853 or the Instructions for Form 8889. Any earnings on the account after the date of death (box 1 minus box 4 of Form 1099-SA) are taxable. Include the earnings on the “Other income” line of your tax return. Account number. May show an account or other unique number the payer assigned to distinguish your account. Box 1. Shows the amount received this year. The amount may have been a direct payment to the medical service provider or distributed to you. Box 2. Shows the earnings on any excess contributions you withdrew from an HSA or Archer MSA by the due date of your income tax return. If you withdrew the excess, plus any earnings, by the due date of your income tax return, you must include the earnings in your income in the year you received the distribution even if you used it to pay qualified medical expenses. This amount is included in box 1. Include the earnings on the “Other income” line of your tax return. An excise tax of 6% for each tax year is imposed on you for excess individual and employer contributions that remain in the account. See Form 5329, Additional Taxes on Qualified Plans (Including IRAs) and Other Tax-Favored Accounts. Box 3. These codes identify the distribution you received: 1—Normal distribution; 2—Excess contributions; 3—Disability; 4—Death distribution other than code 6; 5—Prohibited transaction; 6—Death distribution after year of death to a nonspouse beneficiary. Box 4. If the account holder died, shows the FMV of the account on the date of death. Box 5. Shows the type of account that is reported on this Form 1099-SA. Future developments. For the latest information about developments related to Form 1099-SA and its instructions, such as legislation enacted after they were published, go to www.irs.gov/form1099sa. VOID CORRECTED TRUSTEE'S/PAYER'S name, street address, city or town, state or province, country, ZIP or foreign postal code, and telephone number OMB No. 1545-1517 2016 Form 1099-SA PAYER'S federal identification number RECIPIENT'S identification number RECIPIENT'S name 1 Gross distribution 2 Earnings on excess cont. $ $ 3 Distribution code 4 FMV on date of death $ 5 HSA Street address (including apt. no.) City or town, state or province, country, and ZIP or foreign postal code Archer MSA MA MSA Account number (see instructions) Form 1099-SA Distributions From an HSA, Archer MSA, or Medicare Advantage MSA www.irs.gov/form1099sa Copy C For Trustee/Payer For Privacy Act and Paperwork Reduction Act Notice, see the 2016 General Instructions for Certain Information Returns. Department of the Treasury - Internal Revenue Service Instructions for Trustee/Payer To complete Form 1099-SA, use: • the 2016 General Instructions for Certain Information Returns, and • the 2016 Instructions for Forms 1099-SA and 5498-SA. To order these instructions and additional forms, go to www.irs.gov/form1099sa. Due dates. Furnish Copy B of this form to the recipient by January 31, 2017. File Copy A of this form with the IRS by February 28, 2017. If you file electronically, the due date is March 31, 2017. To file electronically, you must have software that generates a file according to the specifications in Pub. 1220. Need help? If you have questions about reporting on Form 1099-SA, call the information reporting customer service site toll free at 1-866-455-7438 or 304-263-8700 (not toll free). Persons with a hearing or speech disability with access to TTY/TDD equipment can call 304-579-4827 (not toll free).
Extracted from PDF file 2016-federal-form-1099-sa.pdf, last modified November 2015

More about the Federal Form 1099-SA Other TY 2016

We last updated the Distributions From an HSA, Archer MSA, or Medicare Advantage MSA in May 2017, so this is the latest version of Form 1099-SA, fully updated for tax year 2016. You can download or print current or past-year PDFs of Form 1099-SA directly from TaxFormFinder. You can print other Federal tax forms here.


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Form Sources:

The Internal Revenue Service usually releases income tax forms for the current tax year between October and January, although changes to some forms can come even later. We last updated Federal Form 1099-SA from the Internal Revenue Service in May 2017.

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Historical Past-Year Versions of Federal Form 1099-SA

We have a total of six past-year versions of Form 1099-SA in the TaxFormFinder archives, including for the previous tax year. Download past year versions of this tax form as PDFs here:


2016 Form 1099-SA

2016 Form 1099-SA

Distributions From an HSA, Archer MSA, or Medicare Advantage MSA 2015 Form 1099-SA

2016 Form 1099-SA

Distributions From an HSA, Archer MSA, or Medicare Advantage MSA 2014 Form 1099-SA

2014 Form 1099-SA

Distributions From an HSA, Archer MSA, or Medicare Advantage MSA 2013 Form 1099-SA

2013 Form 1099-SA

Distributions From an HSA, Archer MSA, or Medicare Advantage MSA 2012 Form 1099-SA

2013 Form 1099-SA

Distributions From an HSA, Archer MSA, or Medicare Advantage MSA 2011 Form 1099-SA

2012 Form 1099-SA


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