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Fillable Form 1099-SA

Form 1099-SA is a U.S. tax form that reports distributions made from a health savings account (HSA), Archer medical savings account (Archer MSA), or Medicare Advantage medical savings account (MA MSA). Its purpose is to show you (and the Internal Revenue Service) how much money you spent from your account

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What is Form 1099-SA?

Form 1099-SA, Distributions From an HSA, Archer MSA, or Medicare Advantage MSA, is a form issued by the IRS to let taxpayers report distributions made from:

  • Health Savings Account (HSA)
  • Archer Medical Savings Account (MSA)
  • Medicare Advantage Medical Savings Account (MA MSA)

Even if the distribution has been paid directly to a medical service provider or account holder, you can still file the 1099 SA Form. In addition, different plans require you to file separate SA 1099 Forms for each.

Form 1099 SA is used to validate these expenses as deductions to your taxes. An HSA distribution cannot be taxed if you have used the distribution to pay for qualified medical expenses for yourself or an eligible family member. An HSA can also be non-taxable if you roll over the account. The same criteria apply to considering an MSA non-taxable.

On the other hand, MA MSA distributions can only be non-taxable if used for your qualified medical expenses.

If you have not used your distributions from an HSA, MSA, or MA MSA, on qualified medical expenses or have not rolled them over, you must include the distribution in your income when filling out and filing Form 8889, Health Savings Accounts, and Form 8853, Archer MSAs and Long-Term Care Insurance Contracts. This might also result in you, as a taxpayer, paying a penalty.

The taxpayer will not fill out the 1099 SA Tax Form, instead, their trustee will fill it out and the taxpayer will receive it. Depending on the type of account that is involved in Tax Form 1099-SA, the taxpayer will have to file either Form 8889 or Form 8853 with their Form 1040, Individual Income Tax Return, or Form 1040-SR, Tax Return for Seniors.

Furthermore, when a taxpayer inherits an HSA, MSA, or MA MSA account, the trustee must file IRS Form 1099-SA to report this transfer.

How to fill out Form 1099-SA?

Financial institutions that are required to file a 1099-SA form can find a PDF copy on the official IRS government website. They can download and print the form to fill out manually. They can also fill out the form electronically on PDFRun.

Form 1099-SA requires you to fill out three separate copies, each for a different purpose.

  • Copy A - This copy is the one that will be received by the IRS for validation.
  • Copy B - This copy will be sent to the recipient of the distribution for their records.
  • Copy C - This copy will be kept by you for your records.


On Copy A, you will find two checkboxes, one for VOID and one for CORRECTED. If you wish to render a previously filed Form 1099-SA void by filing a new one, check the VOID box. On the other hand, if you are filing the current form to correct information on a previous 1099-SA Form, check the CORRECTED box.

If you have checked CORRECTED, check the same box on Copy B and Copy C as well.

If this is a new form, leave this part blank.

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

First, input your complete name or the complete and registered name of the entity handling the account in question.

Second, input the complete mailing address of the account handler. If this entity is located in a foreign location, following the mailing conventions of that locale.

Payer’s TIN

Input your Tax Identification Number here. This can be your Social Security Number or your Employer Identification Number.

Recipient’s TIN

Input the Tax Identification Number of the recipient of the distribution.

For the safety of the recipient, you may input only the last four digits of their TIN on Copy B and Copy C. However, Copy A must have the entirety of the TIN.

Street Address

Input the mailing address of the recipient, including their apartment number.

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

Input the rest of the recipient’s address here. If the recipient is located outside of the U.S. indicate the country they are in and follow the address conventions of that country.

Account Number

Input the account number of the recipient. This is required if you are filing more than one 1099-SA form for the same recipient, to identify each account. However, regardless of whether you are filing more than one 1099-SA Form, the IRS highly advises you to still input the account number.

For Calendar Year

Input the year you are filing this form.

1 Gross Distribution

Input the total amount of the distribution, including the values inputted in box 2. You are not required to input how much of this distribution is taxable. However, the following is not to be inputted here:

  • A Negative Amount
  • Withdrawal of excess employer contributions
  • Excess MA MSA contributions returned to the Secretary of Health and Human Services

2 Earning on Excess Contributions

Input the total earnings distributed with any excess HSA and MSA contributions returned by the due date of the account holder’s next tax return. Other earnings should be reported on Box 1 instead.

3 Distribution Code

Input the appropriate distribution code.

  • 1 — Normal Distributions
  • 2 — Excess Distributions
  • 3 — Distributions due to Disability
  • 4 — Death Distribution for Spouse. Do not use this with Code 6. Use this code for payments made a year after the date of death of the previous account holder.
  • 5 — Prohibited Transaction under IRC sections 220 [e] [2] and 223 [e] [2], both of which detail how a certain expense can be considered outside of qualified medical expenses
  • 6 — Death Distribution for a non-spousal beneficiary. Do not use this with Code 4. Use this code for payments made a year after the date of death of the previous account holder.

4 FMV on Date of Death

If the account holder has died, input the Fair Market Value (FMV) of the account at the date of death.

Box 5

Indicate from what type of account the distribution from the list below. Check the appropriate box.

  • Health Savings Account (HSA)
  • Archer Medical Savings Account (MSA)
  • Medicare Advantage Medical Savings Account (MA MSA)

Additionally, if you want to access more forms check out the related forms below or click here for the full list of forms related to your 1099-SA.


Keywords: 1099 SA form 2019 irs 1099 sa form 2019 1099-sa 2019 form 1099-sa irs 2019

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