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One account and one distribution code. 2012 Form 1099-SA Distributions from an HSA Account No. National Financial Services LLC Agent for Fidelity Personal Trust Company P.O. Box 673000 Dallas TX 75267-3000 Taxpayer ID. X54-0000000 ***-**-0000 Page 1 of 2 Federal ID Number: 04-3523567JOE Envelope 2100000001 Customer Service:800-544-3716 Visit Us Online:Fidelity.com JOE SAMPLE MAIN STREET ANYTOWN MA 00000-0000 Form 1099-SA 2012 Distributions from an HSA This information is being furnishe.

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