Instructions For Forms 1099-Sa And 5498-Sa - 2006 (Page 4 of 25) in pdf

Box 2. Earnings on Excess Contributions

Rollovers from an IRA, a health reimbursement

arrangement (HRA), or a flexible spending arrangement

Enter the total earnings distributed with any excess HSA or

(FSA) to an HSA are not permitted.

CAUTION

Archer MSA contributions returned by the due date of the

account holder’s tax return. Include this amount in box 1.

Report earnings on other distributions only in box 1. Do not

Total Distribution, No Contributions

report excess MA MSA contributions returned to the Secretary

Generally, if a total distribution was made from an HSA or

of Health and Human Services or his or her representative.

Archer MSA during the year and no contributions were made for

Box 3. Distribution Code

that year, you need not file Form 5498-SA nor furnish a

Enter the appropriate distribution code from the list below that

statement to the participant to reflect that the FMV on

shows the type of distribution.

December 31 was zero.

1 — Normal distributions

Use this code for normal distributions to

Death of Account Holder

the account holder and any direct

In the year an HSA, Archer MSA, or MA MSA owner dies,

payments to a medical service provider.

generally you must file a Form 5498-SA and furnish a statement

Use this code if no other code applies.

for the decedent. If the beneficiary is the spouse:

Also, see Distribution after year of death

•

on page SA-1.

The spouse becomes the account holder of the HSA or

Archer MSA,

2 — Excess contributions

Use this code for distributions of excess

•

The spouse may continue an MA MSA, but no new

HSA or Archer MSA contributions. Do not

contributions may be made to the account, and

use this code for excess MA MSA

•

Distributions from an Archer MSA or MA MSA are taxed

contributions returned to the Secretary of

under the rules that apply to Archer MSAs, not MA MSAs. For

Health and Human Services or his or her

rules that apply to HSAs, see Notice 2004-2, Q/A-31 which is

representative.

on page 269 of Internal Revenue Bulletin 2004-2 at

3 — Disability

Use this code if you made distributions

after the account holder was disabled

If the beneficiary is not the spouse or there is no named

(see section 72(m)(7)).

beneficiary, the account ceases to be an HSA, Archer MSA, or

4 — Death distribution

Use this code for payments to a

MA MSA.

other than code 6

decedent’s estate in the year of death.

Also use this code for payments to an

estate after the year of death. Do not use

Statements to Participants

with code 6. See Death of Account Holder

If you are required to file Form 5498-SA, you must provide a

on page SA-1.

statement to the participant (generally Copy B) by May 31,

5 — Prohibited transaction

See sections 220(e)(2) and 223(e)(2).

2007. You may, but you are not required to, provide participants

with a statement of the December 31, 2006, FMV of the

6 — Death distribution after

Use this code for payments to a

participant’s account by January 31, 2007. For more information

year of death to a

decedent’s nonspouse beneficiary, other

about statements to participants, see part M in the 2006

nonspouse beneficiary

than an estate, after the year of death. Do

General Instructions for Forms 1099, 1098, 5498, and W-2G.

not use with code 4.

Box 4. FMV on Date of Death

Account Number

If the account holder died, enter the FMV of the account on the

The account number is required if you have multiple accounts

date of death. See Death of Account Holder on page SA-1.

for a recipient for whom you are filing more than one Form

Box 5. Checkbox

5498-SA. Additionally, the IRS encourages you to designate an

Check the box to indicate if this distribution was from an HSA,

account number for all Forms 5498-SA that you file. See part L

Archer MSA, or MA MSA.

in the 2006 General Instructions for Forms 1099, 1098, 5498,

and W-2G.

Specific Instructions for Form 5498-SA

Box 1. Employee or Self-Employed Person’s Archer

File Form 5498-SA, HSA, Archer MSA, or Medicare Advantage

MSA Contributions Made in 2006 and 2007 for 2006

MSA Information, with the IRS on or before May 31, 2007, for

Enter the employee’s or self-employed person’s regular

each person for whom you maintained an HSA, Archer MSA, or

contributions to the Archer MSA made in 2006 and through

Medicare Advantage MSA (MA MSA) during 2006. You are

April 16, 2007, for 2006. Report gross contributions, including

required to file if you are the trustee or custodian of an HSA,

any excess contributions, even if the excess contributions were

Archer MSA, or MA MSA. A separate form is required for each

withdrawn. No HSA information is to be reported in box 1.

type of plan.

For HSA or Archer MSA contributions made between

Box 2. Total Contributions Made in 2006

January 1, 2007, and April 16, 2007, you should obtain the

Enter the total HSA or Archer MSA contributions made in 2006.

participant’s designation of the year for which the contributions

Include any contribution made in 2006 for 2005. You may, but

are made.

you are not required to, report the total MA MSA contributions

For repayment of a mistaken distribution amount, see

the Secretary of Health and Human Services or his or her

Mistaken distributions on page SA-1.

representative made in 2006.

Box 3. Total HSA or Archer MSA Contributions Made

Rollovers

in 2007 for 2006

You must report the receipt of a rollover from one Archer MSA

Enter the total HSA or Archer MSA contributions made in 2007

to another Archer MSA, and receipt of a rollover from an Archer

for 2006.

MSA or an HSA to an HSA in box 4.

Box 4. Rollover Contributions.

Enter rollover contributions to the HSA or Archer MSA received

Transfers

by you during 2006.

Do not report a trustee-to-trustee transfer from one Archer MSA

Box 5. Fair Market Value of HSA, Archer MSA, or MA

or MA MSA to another Archer MSA or MA MSA, from an Archer

MSA

MSA to an HSA, or from one HSA to another HSA. For

Enter the FMV of the account on December 31, 2006.

reporting purposes, contributions and rollovers do not include

these transfers.

Box 6. Checkbox

Check the box to indicate if this account is an HSA, Archer

MSA, or MA MSA.

SA-2

Instructions For Forms 1099-Sa And 5498-Sa - 2006 Page 4

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