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See IRS Publications 1141, 1167, 1179 and other IRS resources for information about printing these tax forms. 9494VOIDCORRECTEDTRUSTEE’S/PAYER’S name, street address, city, state, and ZIP codeOMB No. 1545-1517DistributionsFrom an HSA,Archer MSA, or2009Medicare AdvantageMSAForm 1099-SAPAYER’S federal identification numberRECIPIENT’S identification number1Gross distribution2 Earnings on excess cont.Copy A$$ForRECIPIENT’S name3Distribution code4 FMV on date of deathInternal RevenueService Center$File with Form 1096.Street address (including apt. no.)5HSAFor Privacy Actand PaperworkArcherReduction ActMSACity, state, and ZIP codeNotice, see the 2009MAGeneral InstructionsMSAfor Forms 1099,Account number (see instructions)1098, 3921, 3922,5498, and W-2G.Form 1099-SACat. No. 38471DDepartment of the Treasury - Internal Revenue ServiceDo Not Cut or Separate Forms on This Page—Do Not Cut or Separate Forms on This PageCORRECTED (if checked)TRUSTEE’S/PAYER’S name, street address, city, state, and ZIP codeOMB No. 1545-1517DistributionsFrom an HSA,Archer MSA, or2009Medicare AdvantageMSAForm 1099-SAPAYER’S federal identification numberRECIPIENT’S identification number1Gross distribution2 Earnings on excess cont.Copy B$$ForRECIPIENT’S name3Distribution code4 FMV on date of deathRecipient$Street address (including apt. no.)5HSAThis informationArcheris being furnishedMSAto the InternalCity, state, and ZIP codeMARevenue Service.MSAAccount number (see instructions)Form 1099-SA(keep for your records)Department of the Treasury - Internal Revenue ServiceInstructions for RecipientWhat’s new. If any of the distribution relates to your economic stimulussomeone who was not your spouse, you must report as income on your taxpayment, see the instructions for Forms 1040 and 1040A.return the FMV of the account as of the date of death. Report the FMV on yourtax return for the year the account owner died even if you received theDistributions from a health savings account (HSA), Archer MSA, or Medicaredistribution from the account in a later year. See the instructions for FormAdvantage (MA) MSA are reported to you on Form 1099-SA. File Form 8853,8853 or Form 8889. Any earnings on the account after the date of death (boxArcher MSAs and Long-Term Care Insurance Contracts, or Form 8889, Health1 minus box 4 of Form 1099-SA) are taxable. Include the earnings on theSavings Accounts (HSAs), with your Form 1040 to report a distribution from“Other income” line of your tax return.these accounts even if the distribution is not taxable. The payer is not requiredto compute the taxable amount of any distribution.Account number. May show an account or other unique number the payerAn HSA or Archer MSA distribution is not taxable if you used it to payassigned to distinguish your account.qualified medical expenses of the account holder and family or you rolled itBox 1. Shows the amount received this year. The amount may have been aover. An HSA may be rolled over to another HSA; an Archer MSA may bedirect payment to the medical service provider or distributed to you.rolled over to another Archer MSA or an HSA. An MA MSA is not taxable ifBox 2. Shows the earnings on any excess contributions you withdrew from anyou used it to pay qualified medical expenses of the account holder only. IfHSA or Archer MSA by the due date of your income tax return. If you withdrewyou did not use the distribution from an HSA, Archer MSA, or MA MSA to paythe excess, plus any earnings, by the due date of your income tax return, youfor qualified medical expenses, or in the case of an HSA or Archer MSA, youmust include the earnings in your income in the year you received thedid not roll it over, you must include the distribution in your income (see Formdistribution even if you used it to pay qualified medical expenses. This amount8889 or Form 8853). Also, you may owe a penalty.is included in box 1. Include the earnings on the “Other income” line of yourFor more information, see the separate instructions for Form 8853 and Formtax return. An excise tax of 6% for each tax year is imposed on you for excess8889. Also see Pub. 969, Health Savings Accounts and Other Tax-Favoredindividual and employer contributions that remain in the account. See FormHealth Plans.5329, Additional Taxes on Qualified Plans (Including IRAs) and OtherSpouse beneficiary. If you inherited an Archer MSA or MA MSA because ofTax-Favored Accounts.the death of your spouse, special rules apply. See Instructions for Form 8853.Box 3. These codes identify the distribution you received: 1—NormalIf you inherited an HSA because of the death of your spouse, see thedistribution; 2—Excess contributions; 3—Disability; 4—Death distribution otherInstructions for Form 8889.than code 6; 5—Prohibited transaction; 6—Death distribution after year ofEstate beneficiary. If the HSA, Archer MSA, or MA MSA account holder diesdeath to a nonspouse beneficiary.and the estate is the beneficiary, the fair market value (FMV) of the account onBox 4. If the account holder died, shows the FMV of the account on the datethe date of death is includible in the account holder’s gross income. Reportof death.the amount on the account holder’s final income tax return.Box 5. Shows the type of account that is reported on this Form 1099-SA.Nonspouse beneficiary. If you inherited the HSA, Archer MSA, or MA MSA fromVOIDCORRECTEDTRUSTEE’S/PAYER’S name, street address, city, state, and ZIP codeOMB No. 1545-1517DistributionsFrom an HSA,Archer MSA, or2009Medicare AdvantageMSAForm 1099-SAPAYER’S federal identification numberRECIPIENT’S identification number1Gross distribution2 Earnings on excess cont.Copy C$$ForRECIPIENT’S name3Distribution code4FMV on date of deathPayerFor Privacy Act$and PaperworkReduction ActStreet address (including apt. no.)5HSANotice, see the 2009ArcherGeneralMSACity, state, and ZIP codeInstructions forMAForms 1099, 1098,MSA3921, 3922, 5498,Account number (see instructions)and W-2G.Form 1099-SADepartment of the Treasury - Internal Revenue ServiceInstructions for Trustees/PayersGeneral and specific form instructions are provided asFile Copy A of this form with the IRS by separate products. The products you should use toMarch 1, 2010. If you file electronically, the due date iscomplete Form 1099-SA are the 2009 GeneralMarch 31, 2010. To file electronically, you must haveInstructions for Forms 1099, 1098, 3921, 3922, 5498,software that generates a file according to theand W-2G and the 2009 Instructions for Formsspecifications in Pub. 1220, Specifications for Filing1099-SA and 5498-SA. A chart in the generalForms 1098, 1099, 3921, 3922, 5498, and W-2Ginstructions gives a quick guide to which form must beElectronically. IRS does not provide a fill-in formfiled to report a particular payment. To order theseoption.instructions and additional forms, visit the IRS websiteNeed help? If you have questions about reporting onat www.irs.gov or call 1-800-TAX-FORMForm 1099-SA, call the information reporting customer(1-800-829-3676).service site toll free at 1-866-455-7438 orCaution: Because paper forms are scanned during304-263-8700 (not toll free). For TTY/TDD equipment,processing, you cannot file Forms 1096, 1098, 1099,call 304-267-3367 (not toll free).3921, 3922, or 5498 that you print from the IRSwebsite.Due dates. Furnish Copy B of this form to therecipient by February 1, 2010.