Form 1099-Sa - Distributions From An Hsa, Archer Msa, Or Medicare Advantage Msa - 2016 Page 2
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5CORRECTED (if checked)
TRUSTEE'S/PAYER'S name, street address, city or town, state or province,
OMB No. 1545-1517
Distributions
country, ZIP or foreign postal code, and telephone number
From an HSA,
2016
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 or town, state or province, country, and ZIP or foreign postal 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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