EFTA01222608.pdf

ri VOID n CORRECTED TRUSTEE &PAYER S name. street address. city or town. state or province. O0.18 No. 1545-1517 country. ZIP or foreign postal code. and telephone number Distributions From an HSA, 2018 Archer MSA, or Medicare Advantage MSA JI Form 1099-SA PAYER'S TIN RECIPIENT'S TIN 1 Gross distribution 2 Earnings on excess cont. Copy A For Internal Revenue RECIPIENT'S name 3 Distribution code 4 FMV on date of death Service Center File with Form 1096. $ For Privacy Act Street address (including apt. no.) S HSA and Paperwork Reduction Act Archer MSA ❑ Notice. see the City or town. state or province. country. and ZIP or foreign postal code 2018 General MA MSA Instructions for Certain Account number (see instructions) Information Returns. Form 1099-SA vmw.irs.gowForm1099SA Department of the Treasury - Internal Revenue Service EFTA01222608