How to Fill Out IRS Form 1099-SA. IRS Form 1099-SA, titled "Distributions From an HSA, Archer MSA, or Medicare Advantage MSA," is sent to those taxpayers who received monetary disbursements from health savings accounts (HSAs) or medical savings accounts (MSAs). The recipient doesn't complete it.
Call (800) TAX-FORM or visit the IRS online form ordering website to obtain acceptable copies of Form 1099-SA to send to recipients. Although Form 1099-SA is available for viewing online, the e-version of the form is unacceptable to send to taxpayers or the Internal Revenue Service.
Check the "Void" or "Corrected" box at the top of the 1099 form if applicable. Enter the Trustee's/Payer's name, street address, city, state and ZIP code in the first box. The Trustee/Payer is the organization or entity that disbursed the HSA/MSA money.
Enter the Payer's Federal identification number and the Recipient's identification number in the two boxes beneath the first box. Below this, list the Recipient's name, street address (including apartment number), city, state and ZIP code. Enter the account number that is associated with this distribution of money.
Show the HSA/MSA amount paid this year in Box 1. The amount may have been a payment to a medical service provider or sent directly to the Recipient. In Box 2, list the earnings on any excess contributions the Recipient withdrew from an HSA/MSA. Indicate the appropriate code in Box 3 for the type of distribution: 1, Normal distribution; 2, Excess contributions; 3, Disability; 4, Death distribution other than code 6; 5, Prohibited transaction; or 6, Death distribution after year of death to a non-spouse beneficiary.
Indicate the fair market value (FMV) of the account if the account holder died (as of the date of death) in Box 4. In Box 5, show the type of account that is reported on this form: HSA, Archer MSA or Medicare Advantage MSA.
File Form 1099-SA with the IRS; also send a copy to the recipient. Check the IRS official website (see resources below) for specific instructions as to the filing deadline for Form 1099-SA; it changes annually.