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Instructions for Recipient

Distributions from a health savings account (HSA), Archer MSA, or Medicare

or Form 8889. Any earnings on the account after the date of death (box 1

Advantage (MA) MSA are reported to you on Form 1099-SA. File Form 8853 or

minus box 4 of Form 1099-SA) are taxable. Include the earnings on the “Other

Form 8889 with your Form 1040 to report a distribution from these accounts

income” line of your tax return.

even if the distribution is not taxable. The payer is not required to compute the

Account number. May show an account or other unique number the payer

taxable amount of any distribution.

assigned to distinguish your account.

An HSA or Archer MSA distribution is not taxable if you used it to pay qualified

Box 1. Shows the amount received this year. The amount may have been a

medical expenses of the account holder and family or you rolled it over. An HSA may

direct payment to the medical service provider or distributed to you.

be rolled over to another HSA; an Archer MSA may be rolled over to another Archer

Box 2. Shows the earnings on any excess contributions you withdrew from an

MSA or an HSA. An MA MSA is not taxable if you used it to pay qualified medical

HSA or Archer MSA by the due date of your income tax return. If you withdrew

expenses of the account holder only. If you did not use the distribution from an HSA,

the excess, plus any earnings, by the due date of your income tax return, you

Archer MSA, or MA MSA to pay for qualified medical expenses, or in the case of an

must include the earnings in your income in the year you received the

HSA or Archer MSA, you did not roll it over, you must include the distribution in your

distribution even if you used it to pay qualified medical expenses. This amount is

income (see Form 8853 or Form 8889). Also, you may owe a penalty.

included in box 1. Include the earnings on the “Other income” line of your tax

For more information, see the separate instructions for Form 8853 and Form

return. An excise tax of 6% for each tax year is imposed on you for excess

8889. Also see Pub. 969.

individual and employer contributions that remain in the account. See Form

Spouse beneficiary. If you inherited an Archer MSA or MA MSA because of the

5329, Additional Taxes on Qualified Plans (Including IRAs) and Other Tax-

death of your spouse, special rules apply. See the Instructions for Form 8853. If

Favored Accounts.

you inherited an HSA because of the death of your spouse, see the Instructions

Box 3. These codes identify the distribution you received: 1—Normal

for Form 8889.

distribution; 2—Excess contributions; 3—Disability; 4—Death distribution other

Estate beneficiary. If the HSA, Archer MSA, or MA MSA account holder dies

than code 6; 5—Prohibited transaction; 6—Death distribution after year of death

and the estate is the beneficiary, the fair market value (FMV) of the account on

to a nonspouse beneficiary.

the date of death is includible in the account holder’s gross income.

Box 4. If the account holder died, shows the FMV of the account on the date of

Report the amount on the account holder’s final income tax return.

death.

Nonspouse beneficiary. If you inherited the HSA, Archer MSA, or MA MSA

Box 5. Shows the type of account that is reported on this Form 1099-SA.

from someone who was not your spouse, you must report as income on your

Future developments. For the latest information about developments related to

tax return the FMV of the account as of the date of death. Report the FMV on

Form 1099-SA, such as legislation enacted after this form and instruction were

your tax return for the year the account owner died even if you received the

published, go to

distribution from the account in a later year. See the instructions for Form 8853

Form 1099-Sa - Distributions From An Hsa, Archer Msa, Or Medicare Advantage Msa - 2013 Page 4

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