Form 1099-Sa - Distributions From An Hsa, Archer Msa, Or Medicare Advantage Msa - 2013 Page 2
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69494
VOID
CORRECTED
TRUSTEE'S/PAYER'S name, street address, city or town, province or state,
OMB No. 1545-1517
Distributions
country, ZIP or foreign postal code, and telephone number
From an HSA,
2013
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
2013 General
City or town, province or state, country, and ZIP or foreign postal 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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