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  • Health Savings Account (hsa) Distribution Form - Nbsc

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1148 Broadway Columbus, GA 31901 HSA OWNER INFORMATION NAME, ADDRESS, CITY, STATE, AND ZIP DAYTIME PHONE NUMBER E-MAIL (OPTIONAL) HSA ACCOUNT NUMBER SOCIAL SECURITY NUMBER (SSN) DISTRIBUTION REASON DATE OF BIRTH DATE OF DEATH (IF APPLICABLE) (For further information, see Additional Information included with this form.) Select One. l Normal l Death Type of Beneficiary: l Estate l Other Distribution is in: l Year of Death l After Year of Death Fair Market Value of HSA as of Date of Death.

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Amounts shown on Form 1099-SA must be reported on the taxpayer's federal income tax form.

File Form 1099-SA to report distributions made from a: Health savings account (HSA).

IRS Form 1099-SA is provided for each HSA distribution you made in the current tax year. You will receive a separate 1099-SA for each type of distribution made during the tax year. The five distribution types are 1) normal; 2) excess contribution removal; 3) death; 4) disability; and 5) prohibited transaction.

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.

HSA distributions are reported to the account owner on Form 1099-SA. This form is issued by the financial institution.

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.

Use Form 8889 to: Report health savings account (HSA) contributions (including those made on your behalf and employer contributions), Figure your HSA deduction, Report distributions from HSAs, and. Figure amounts you must include in income and additional tax you may owe if you fail to be an eligible individual.

The 1099-SA is used to report any distribution (withdrawal) of funds from your HSA during the prior year. You must report distributions from your HSA on IRS Form 8889. There's a sample 1099-SA form from the IRS here. The HSA Bank 1099-SA form may look slightly different, but it will contain the same information.

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© Copyright 1997-2025
airSlate Legal Forms, Inc.
3720 Flowood Dr, Flowood, Mississippi 39232
Form Packages
Adoption
Bankruptcy
Contractors
Divorce
Home Sales
Employment
Identity Theft
Incorporation
Landlord Tenant
Living Trust
Name Change
Personal Planning
Small Business
Wills & Estates
Packages A-Z
Form Categories
Affidavits
Bankruptcy
Bill of Sale
Corporate - LLC
Divorce
Employment
Identity Theft
Internet Technology
Landlord Tenant
Living Wills
Name Change
Power of Attorney
Real Estate
Small Estates
Wills
All Forms
Forms A-Z
Form Library
Customer Service
Terms of Service
DMCA Policy
About Us
Blog
Affiliates
Contact Us
Privacy Notice
Delete My Account
Site Map
Industries
Forms in Spanish
Localized Forms
State-specific Forms
Forms Kit
Legal Guides
Real Estate Handbook
All Guides
Prepared for You
Notarize
Incorporation services
Our Customers
For Consumers
For Small Business
For Attorneys
Our Sites
US Legal Forms
USLegal
FormsPass
pdfFiller
signNow
airSlate workflows
DocHub
Instapage
Social Media
Call us now toll free:
1-877-389-0141
As seen in:
  • USA Today logo picture
  • CBC News logo picture
  • LA Times logo picture
  • The Washington Post logo picture
  • AP logo picture
  • Forbes logo picture
© Copyright 1997-2025
airSlate Legal Forms, Inc.
3720 Flowood Dr, Flowood, Mississippi 39232