Federal Distributions From an HSA, Archer MSA, or Medicare Advantage MSA
Extracted from PDF file 2023-federal-form-1099-sa.pdf, last modified October 2019Distributions From an HSA, Archer MSA, or Medicare Advantage MSA
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 Form 1099-SA (Rev. November 2019) For calendar year 20 PAYER’S TIN RECIPIENT’S TIN 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 current General Instructions for Certain Information Returns. 1099-SA (Rev. 11-2019) 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 Form 1099-SA (Rev. November 2019) For calendar year 20 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 TIN RECIPIENT’S TIN 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 IRS. Account number (see instructions) Form 1099-SA (Rev. 11-2019) (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 or 1040-SR to report a distribution from these accounts even if the distribution isn’t taxable. The payer isn’t required to compute the taxable amount of any distribution. An HSA or Archer MSA distribution isn’t 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 isn’t taxable if you used it to pay qualified medical expenses of the account holder only. If you didn’t 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 didn’t 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. Recipient’s taxpayer identification number (TIN). For your protection, this form may show only the last four digits of your TIN (SSN, ITIN, ATIN, or EIN). However, the issuer has reported your complete identification number to the IRS. 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 wasn’t 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 Form 1099-SA (Rev. November 2019) For calendar year 20 PAYER’S TIN RECIPIENT’S TIN 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 (Rev. 11-2019) 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 current General Instructions for Certain Information Returns. Department of the Treasury - Internal Revenue Service Instructions for Trustee/Payer To complete Form 1099-SA, use: • The current General Instructions for Certain Information Returns, and • The current Instructions for Forms 1099-SA and 5498-SA. To get or to order these instructions, go to www.irs.gov/Form1099SA. Filing and furnishing. For filing and furnishing instructions, including due dates, and to request filing or furnishing extensions, see the current General Instructions for Certain Information Returns. 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 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).
Form 1099-SA (Rev. 11-2019)
More about the Federal Form 1099-SA Corporate Income Tax Estimated TY 2023
We last updated the Distributions From an HSA, Archer MSA, or Medicare Advantage MSA in February 2024, so this is the latest version of Form 1099-SA, fully updated for tax year 2023. 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 February 2024.
Form 1099-SA is a Federal Corporate Income Tax form. While most taxpayers have income taxes automatically withheld every pay period by their employer, taxpayers who earn money that is not subject to withholding (such as self employed income, investment returns, etc) are often required to make estimated tax payments on a quarterly basis. Failure to make correct estimated payments can result in interest or penalties.
About the Corporate Income Tax
The IRS and most states require corporations to file an income tax return, with the exact filing requirements depending on the type of company.
Sole proprietorships or disregarded entities like LLCs are filed on Schedule C (or the state equivalent) of the owner's personal income tax return, flow-through entities like S Corporations or Partnerships are generally required to file an informational return equivilent to the IRS Form 1120S or Form 1065, and full corporations must file the equivalent of federal Form 1120 (and, unlike flow-through corporations, are often subject to a corporate tax liability).
Additional forms are available for a wide variety of specific entities and transactions including fiduciaries, nonprofits, and companies involved in other specific types of business.
Historical Past-Year Versions of Federal Form 1099-SA
We have a total of thirteen 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:
Form 1099-SA (Rev. 11-2019)
Form 1099-SA (Rev. 11-2019)
Form 1099-SA (Rev. 11-2019)
Form 1099-SA (Rev. 11-2019)
Form 1099-SA (Rev. 11-2019)
2018 Form 1099-SA
2017 Form 1099-SA
2016 Form 1099-SA
2016 Form 1099-SA
2014 Form 1099-SA
2013 Form 1099-SA
2013 Form 1099-SA
2012 Form 1099-SA
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