Form 1099-Sa - Distributions From An Hsa, Archer Msa, Or Medicare Advantage Msa - 2016 Page 4
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CORRECTED
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 C
PAYER'S federal identification number
RECIPIENT'S identification number
1 Gross distribution
2 Earnings on excess cont.
$
$
For
Trustee/Payer
RECIPIENT'S name
4 FMV on date of death
3 Distribution code
For Privacy Act
$
and Paperwork
Reduction Act
Street address (including apt. no.)
5 HSA
Notice, see the
Archer
2016 General
MSA
City or town, state or province, country, and ZIP or foreign postal code
Instructions for
MA
Certain
MSA
Information
Account number (see instructions)
Returns.
1099-SA
Form
Department of the Treasury - Internal Revenue Service
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