1099-SA Distributions From an HSA, Archer MSA or Medical Advanta

Note: The draft you are looking for begins on the next page.

Caution: DRAFT—NOT FOR FILING

This is an early release draft of an IRS tax form, instructions, or publication,
which the IRS is providing for your information. Do not file draft forms and do
not rely on draft forms, instructions, and pubs for filing. We incorporate all
significant changes to forms posted with this coversheet. However, unexpected
issues occasionally arise, or legislation is passed—in this case, we will post a
new draft of the form to alert users that changes were made to the previously
posted draft. Thus, there are never any changes to the last posted draft of a
form and the final revision of the form. Forms and instructions are subject to
OMB approval before they can be officially released, so we post drafts of them
until they are approved. Drafts of instructions and pubs usually have some
additional changes before their final release. Early release drafts are at
IRS.gov/DraftForms and remain there after the final release is posted at
IRS.gov/LatestForms. Also see IRS.gov/Forms.
Most forms and publications have a page on IRS.gov: IRS.gov/Form1040 for
Form 1040; IRS.gov/Pub501 for Pub. 501; IRS.gov/W4 for Form W-4; and
IRS.gov/ScheduleA for Schedule A (Form 1040), for example, and similarly for
other forms, pubs, and schedules for Form 1040. When typing in a link, type it
into the address bar of your browser, not a Search box on IRS.gov.
If you wish, you can submit comments to the IRS about draft or final forms,
instructions, or pubs at IRS.gov/FormsComments. Include “NTF” followed by the
form or pub number (for example, “NTF1040”, “NTFW4”, “NTF501, etc.) in the
body of the message to route your message properly. We cannot respond to all
comments due to the high volume we receive and may not be able to consider
many suggestions until the subsequent revision of the product, but we will
review each “NTF” message. If you have comments on reducing paperwork and
respondent (filer) burden, with respect to draft or final forms, please respond to
the relevant information collection through the Federal Register process; for
more info, click here.

9494

VOID

CORRECTED

TRUSTEE’S/PAYER’S name, street address, city or town, state or province,
country, ZIP or foreign postal code, and telephone number

OMB No. 1545-1517
Form

1099-SA

(Rev. November 2024)
For calendar year

Distributions
From an HSA,
Archer MSA, or
Medicare Advantage
MSA

1 Gross distribution

2 Earnings on excess cont.

$

$

RECIPIENT’S name

3 Distribution code

4 FMV on date of death

Street address (including apt. no.)

5 HSA

PAYER’S TIN

RECIPIENT’S TIN

TREASURY/IRS
AND OMB USE
ONLY DRAFT
June 5, 2024
DO NOT FILE
$

City or town, state or province, country, and ZIP or foreign postal code
Account number (see instructions)

Archer
MSA
MA
MSA

Copy A

For
Internal Revenue
Service Center

For filing information,
Privacy Act, and
Paperwork Reduction
Act Notice, see the
General Instructions
for Certain
Information
Returns.
www.irs.gov/Form1099

1099-SA (Rev. 11-2024)
Cat. No. 38471D
Department of the Treasury - Internal Revenue Service
www.irs.gov/Form1099SA
Do Not Cut or Separate Forms on This Page — Do Not Cut or Separate Forms on This Page

Form

CORRECTED (if checked)
TRUSTEE’S/PAYER’S name, street address, city or town, state or province,
country, ZIP or foreign postal code, and telephone number

OMB No. 1545-1517
Form

1099-SA

(Rev. November 2024)
For calendar year

Distributions
From an HSA,
Archer MSA, or
Medicare Advantage
MSA

1 Gross distribution

2 Earnings on excess cont.

$

$

RECIPIENT’S name

3 Distribution code

4 FMV on date of death

Street address (including apt. no.)

5 HSA

PAYER’S TIN

RECIPIENT’S TIN

TREASURY/IRS
AND OMB USE
ONLY DRAFT
June 5, 2024
DO NOT FILE

Copy B
For
Recipient

$

City or town, state or province, country, and ZIP or foreign postal code

Archer
MSA
MA
MSA

This information
is being furnished
to the IRS.

Account number (see instructions)
Form

1099-SA (Rev. 11-2024)

(keep for your records)

www.irs.gov/Form1099SA

Department of the Treasury - Internal Revenue Service

Instructions for Recipient

Distributions from a health savings account (HSA), Archer medical savings account
(MSA), or Medicare Advantage (MA) MSA are reported to you on Form 1099-SA. File
Form 8853 or Form 8889 with your Form 1040 or 1040-SR to report a distribution from
these accounts even if the distribution isn’t taxable. The payer isn’t required to
compute the taxable amount of any distribution.
An HSA or Archer MSA distribution isn’t taxable if you used it to pay qualified
medical expenses of the account holder or eligible family member or you rolled it over.
An HSA may be rolled over to another HSA; an Archer MSA may be rolled over to
another Archer MSA or an HSA. An MA MSA isn’t taxable if you used it to pay qualified
medical expenses of the account holder only. If you didn’t use the distribution from an
HSA, Archer MSA, or MA MSA to pay for qualified medical expenses, or in the case of
an HSA or Archer MSA, you didn’t roll it over, you must include the distribution in your
income (see Form 8853 or Form 8889). Also, you may owe a penalty.
You may repay a mistaken distribution from an HSA no later than the due date of
the tax return (not including extensions) following the first year you knew or should
have known the distribution was a mistake, providing the trustee allows the
repayment.
For more information, see the Instructions for Form 8853 and the Instructions for
Form 8889. Also see Pub. 969.
Recipient’s taxpayer identification number (TIN). For your protection, this form may
show only the last four digits of your TIN (SSN, ITIN, ATIN, or EIN). However, the issuer
has reported your complete identification number to the IRS.
Spouse beneficiary. If you inherited an Archer MSA or MA MSA because of the death
of your spouse, special rules apply. See the Instructions for Form 8853. If you inherited
an HSA because of the death of your spouse, see the Instructions for Form 8889.
Estate beneficiary. If the HSA, Archer MSA, or MA MSA account holder dies and the
estate is the beneficiary, the fair market value (FMV) of the account on the date of
death is includible in the account holder’s gross income. Report the amount on the
account holder’s final income tax return.

Nonspouse beneficiary. If you inherited the HSA, Archer MSA, or MA MSA from
someone who wasn’t your spouse, you must report as income on your tax return the
FMV of the account as of the date of death. Report the FMV on your tax return for the
year the account owner died even if you received the distribution from the account in a
later year. See the Instructions for Form 8853 or the Instructions for Form 8889. Any
earnings on the account after the date of death (box 1 minus box 4 of Form 1099-SA)
are taxable. Include the earnings on the “Other income” line of your tax return.
Account number. May show an account or other unique number the payer assigned
to distinguish your account.
Box 1. Shows the amount received this year. The amount may have been a direct
payment to the medical service provider or distributed to you.
Box 2. Shows the earnings on any excess contributions you withdrew from an HSA or
Archer MSA by the due date of your income tax return. If you withdrew the excess,
plus any earnings, by the due date of your income tax return (including extensions),
you must include the earnings in your income in the year you received the distribution
even if you used it to pay qualified medical expenses. This amount is included in box
1. Include the earnings on the “Other income” line of your tax return. An excise tax of
6% for each tax year is imposed on you for excess individual and employer
contributions that remain in the account. See Form 5329, Additional Taxes on
Qualified Plans (Including IRAs) and Other Tax-Favored Accounts.
Box 3. These codes identify the distribution you received: 1—Normal distribution;
2—Excess contributions; 3—Disability; 4—Death distribution other than code 6;
5—Prohibited transaction; 6—Death distribution after year of death to a nonspouse
beneficiary.
Box 4. If the account holder died, shows the FMV of the account on the date of death.
Box 5. Shows the type of account that is reported on this Form 1099-SA.
Future developments. For the latest information about developments related to Form
1099-SA and its instructions, such as legislation enacted after they were published, go
to www.irs.gov/Form1099SA.
Free File Program. Go to www.irs.gov/FreeFile to see if you qualify for no-cost online
federal tax preparation, e-filing, and direct deposit or payment options.

TREASURY/IRS
AND OMB USE
ONLY DRAFT
June 5, 2024
DO NOT FILE