Free 2009 Form 1099-SA - Federal

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OMB No. 1545-1517

TRUSTEE'S/PAYER'S name, street address, city, state, and ZIP code

2009
Form 1099-SA PAYER'S federal identification number RECIPIENT'S identification number 1 Gross distribution

Distributions From an HSA, Archer MSA, or Medicare Advantage MSA
Copy A
For Internal Revenue Service Center
File with Form 1096. For Privacy Act and Paperwork Reduction Act Notice, see the 2009 General Instructions for Forms 1099, 1098, 3921, 3922, 5498, and W-2G.

2 Earnings on excess cont.

$
RECIPIENT'S name 3 Distribution code

$
4 FMV on date of death

$
Street address (including apt. no.) 5 HSA Archer MSA MA MSA

City, state, and ZIP code

Account number (see instructions)

Form 1099-SA

Cat. No. 38471D

Department of the Treasury - Internal Revenue Service

Do Not Cut or Separate Forms on This Page

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Do Not Cut or Separate Forms on This Page

CORRECTED (if checked)
TRUSTEE'S/PAYER'S name, street address, city, state, and ZIP code OMB No. 1545-1517

2009
Form 1099-SA PAYER'S federal identification number RECIPIENT'S identification number 1 Gross distribution

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

2 Earnings on excess cont.

$
RECIPIENT'S name 3 Distribution code

$
4 FMV on date of death

For Recipient
This information is being furnished to the Internal Revenue Service.

$
Street address (including apt. no.) 5 HSA Archer MSA MA MSA

City, state, and ZIP code

Account number (see instructions)

Form 1099-SA

(keep for your records)

Department of the Treasury - Internal Revenue Service

Instructions for Recipient
What's new. If any of the distribution relates to your economic stimulus payment, see the instructions for Forms 1040 and 1040A. Distributions from a health savings account (HSA), Archer MSA, or Medicare Advantage (MA) MSA are reported to you on Form 1099-SA. File Form 8853, Archer MSAs and Long-Term Care Insurance Contracts, or Form 8889, Health Savings Accounts (HSAs), with your Form 1040 to report a distribution from these accounts even if the distribution is not taxable. The payer is not required to compute the taxable amount of any distribution. An HSA or Archer MSA distribution is not taxable if you used it to pay qualified medical expenses of the account holder and family 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 is not taxable if you used it to pay qualified medical expenses of the account holder only. If you did not 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 did not roll it over, you must include the distribution in your income (see Form 8889 or Form 8853). Also, you may owe a penalty. For more information, see the separate instructions for Form 8853 and Form 8889. Also see Pub. 969, Health Savings Accounts and Other Tax-Favored Health Plans. Spouse beneficiary. If you inherited an Archer MSA or MA MSA because of the death of your spouse, special rules apply. See 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 was not 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 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, 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.

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CORRECTED
OMB No. 1545-1517

TRUSTEE'S/PAYER'S name, street address, city, state, and ZIP code

2009
Form 1099-SA PAYER'S federal identification number RECIPIENT'S identification number 1 Gross distribution

Distributions From an HSA, Archer MSA, or Medicare Advantage MSA
Copy C
For Payer
For Privacy Act and Paperwork Reduction Act Notice, see the 2009 General Instructions for Forms 1099, 1098, 3921, 3922, 5498, and W-2G.

2 Earnings on excess cont.

$
RECIPIENT'S name 3 Distribution code

$
4 FMV on date of death

$
Street address (including apt. no.) 5 HSA Archer MSA MA MSA

City, state, and ZIP code

Account number (see instructions)

Form 1099-SA

Department of the Treasury - Internal Revenue Service

Instructions for Trustees/Payers
General and specific form instructions are provided as separate products. The products you should use to complete Form 1099-SA are the 2009 General Instructions for Forms 1099, 1098, 3921, 3922, 5498, and W-2G and the 2009 Instructions for Forms 1099-SA and 5498-SA. A chart in the general instructions gives a quick guide to which form must be filed to report a particular payment. To order these instructions and additional forms, visit the IRS website at www.irs.gov or call 1-800-TAX-FORM (1-800-829-3676). Caution: Because paper forms are scanned during processing, you cannot file Forms 1096, 1098, 1099, 3921, 3922, or 5498 that you print from the IRS website. Due dates. Furnish Copy B of this form to the recipient by February 1, 2010. File Copy A of this form with the IRS by March 1, 2010. If you file electronically, the due date is March 31, 2010. To file electronically, you must have software that generates a file according to the specifications in Pub. 1220, Specifications for Filing Forms 1098, 1099, 3921, 3922, 5498, and W-2G Electronically. IRS does not provide a fill-in form option. Need help? If you have questions about reporting on Form 1099-SA, call the information reporting customer service site toll free at 1-866-455-7438 or 304-263-8700 (not toll free). For TTY/TDD equipment, call 304-267-3367 (not toll free).