Form 1099-SA Template

Use this form to report distributions from an HSA, Archer MSA, or Medicare Advantage MSA.

By using this template, you agree to our Template Terms of Use.

Why use a Form 1099-SA?

A Form 1099-SA helps trustees or payers document account distributions
and account-type details.

Record distributions

Capture gross distributions and earnings on excess contributions for the account.
Identify the account

Mark whether the distribution relates to an HSA, Archer MSA, or MA MSA.
Guide recipient reporting

Provide recipient instructions with distribution codes and related reporting references.

This template includes payer, recipient, distribution, account-type, and date-of-death reporting fields.

Payer information
Fields for trustee or payer name, address, telephone number, and taxpayer identification number.
Recipient information
Fields for recipient name, address, taxpayer identification number, and account number.
Distribution amounts
Fields for gross distribution and earnings on excess contributions.
Distribution code
A field for the code that identifies the type of distribution received.
Account type checkboxes
Checkboxes to identify HSA, Archer MSA, or Medicare Advantage MSA distributions.
Date-of-death value
A field for the fair market value of the account on the date of death.