Form 1099-Sa - Distributions From An Hsa, Archer Msa, Or Medicare Advantage Msa - 2012 Page 2
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69494
VOID
CORRECTED
TRUSTEE'S/PAYER'S name, street address, city, state, and ZIP code
OMB No. 1545-1517
Distributions
From an HSA,
2012
Archer MSA, or
Medicare Advantage
MSA
1099-SA
Form
Copy A
PAYER'S federal identification number
RECIPIENT'S identification number
1 Gross distribution
2 Earnings on excess cont.
For
$
$
Internal Revenue
RECIPIENT'S name
3 Distribution code
4 FMV on date of death
Service Center
File with Form 1096.
$
For Privacy Act
and Paperwork
Street address (including apt. no.)
5 HSA
Reduction Act
Archer
Notice, see the
MSA
2012 General
City, state, and ZIP code
MA
Instructions for
MSA
Certain
Account number (see instructions)
Information
Returns.
1099-SA
Form
Cat. No. 38471D
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
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