Form 1099-Sa - Distributions From An Hsa, Archer Msa, Or Medicare Advantage Msa - 2012 Page 3

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CORRECTED (if checked)
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 B
PAYER'S federal identification number
RECIPIENT'S identification number
1 Gross distribution
2 Earnings on excess cont.
$
$
For
Recipient
RECIPIENT'S name
3 Distribution code
4 FMV on date of death
$
Street address (including apt. no.)
5 HSA
This information
Archer
is being furnished
MSA
City, state, and ZIP code
to the Internal
MA
MSA
Revenue Service.
Account number (see instructions)
1099-SA
(keep for your records)
Form
Department of the Treasury - Internal Revenue Service

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