Form 1099-Sa - Distributions From An Hsa, Archer Msa, Or Medicare Advantage Msa - 2016 Page 3
Download a blank fillable Form 1099-Sa - Distributions From An Hsa, Archer Msa, Or Medicare Advantage Msa - 2016 in PDF format just by clicking the "DOWNLOAD PDF" button.
Open the file in any PDF-viewing software. Adobe Reader or any alternative for Windows or MacOS are required to access and complete fillable content.
Complete Form 1099-Sa - Distributions From An Hsa, Archer Msa, Or Medicare Advantage Msa - 2016 with your personal data - all interactive fields are highlighted in places where you should type, access drop-down lists or select multiple-choice options.
Some fillable PDF-files have the option of saving the completed form that contains your own data for later use or sending it out straight away.
ADVERTISEMENT
1
2
3
4
5Instructions for Recipient
Nonspouse beneficiary. If you inherited the HSA, Archer MSA, or MA MSA
from someone who was not your spouse, you must report as income on your
Distributions from a health savings account (HSA), Archer medical savings
tax return the FMV of the account as of the date of death. Report the FMV on
account (MSA), or Medicare Advantage (MA) MSA are reported to you on
your tax return for the year the account owner died even if you received the
Form 1099-SA. File Form 8853 or Form 8889 with your Form 1040 to report a
distribution from the account in a later year. See the Instructions for Form 8853
distribution from these accounts even if the distribution is not taxable. The payer
or the Instructions for Form 8889. Any earnings on the account after the date of
is not required to compute the taxable amount of any distribution.
death (box 1 minus box 4 of Form 1099-SA) are taxable. Include the earnings on
An HSA or Archer MSA distribution is not taxable if you used it to pay
the “Other income” line of your tax return.
qualified medical expenses of the account holder or eligible family member or
Account number. May show an account or other unique number the payer
you rolled it over. An HSA may be rolled over to another HSA; an Archer MSA
assigned to distinguish your account.
may be rolled over to another Archer MSA or an HSA. An MA MSA is not taxable
Box 1. Shows the amount received this year. The amount may have been a
if you used it to pay qualified medical expenses of the account holder only. If
direct payment to the medical service provider or distributed to you.
you did not use the distribution from an HSA, Archer MSA, or MA MSA to pay
Box 2. Shows the earnings on any excess contributions you withdrew from an HSA
for qualified medical expenses, or in the case of an HSA or Archer MSA, you did
or Archer MSA by the due date of your income tax return. If you withdrew the
not roll it over, you must include the distribution in your income (see Form 8853
excess, plus any earnings, by the due date of your income tax return, you must
or Form 8889). Also, you may owe a penalty.
include the earnings in your income in the year you received the distribution even if
You may repay a mistaken distribution from an HSA no later than April 15
you used it to pay qualified medical expenses. This amount is included in box 1.
following the first year you knew or should have known the distribution was a
Include the earnings on the “Other income” line of your tax return. An excise tax of
mistake, providing the trustee allows the repayment.
6% for each tax year is imposed on you for excess individual and employer
For more information, see the Instructions for Form 8853 and the Instructions
contributions that remain in the account. See Form 5329, Additional Taxes on
for Form 8889. Also see Pub. 969.
Qualified Plans (Including IRAs) and Other Tax-Favored Accounts.
Spouse beneficiary. If you inherited an Archer MSA or MA MSA because of the
Box 3. These codes identify the distribution you received: 1—Normal
death of your spouse, special rules apply. See the Instructions for Form 8853. If
distribution; 2—Excess contributions; 3—Disability; 4—Death distribution other
you inherited an HSA because of the death of your spouse, see the Instructions
than code 6; 5—Prohibited transaction; 6—Death distribution after year of death
for Form 8889.
to a nonspouse beneficiary.
Estate beneficiary. If the HSA, Archer MSA, or MA MSA account holder dies
Box 4. If the account holder died, shows the FMV of the account on the date of death.
and the estate is the beneficiary, the fair market value (FMV) of the account on
Box 5. Shows the type of account that is reported on this Form 1099-SA.
the date of death is includible in the account holder’s gross income. Report the
Future developments. For the latest information about developments related to
amount on the account holder’s final income tax return.
Form 1099-SA and its instructions, such as legislation enacted after they were
published, go to
ADVERTISEMENT
0 votes
Related Articles
Related forms
Form 1099-q - Payments From Qualified Education Programs (under Sections 529 And 530) - 2016
Financial
Form 1099-r - Distributions From Pensions, Annuities, Retirement Or Profit-sharing Plans, Iras, Insurance Contracts, Etc. - 2016
Financial
Related Categories
Parent category: Financial