EFTA01222607.pdf

n CORRECTED (if checked) TRUSTEE'S/PAYER'S name. street address. city or town. state or province. OMB No.1545-1517 coixtry. ZIP or foreign postal code. and telephone number Distributions From an HSA, 2017 Archer MSA, or Medicare Advantage MSA Form 1099-SA PAYER'S federal identification number RECIPIENT'S identification number 1 Gross dtstnbution 2 Earnings on excess cont. Copy B $ For RECIPIENT'S name 3 Distribution code 4 FMV on date of death Recipient $ Street address (including apt. no.) S HSA O This information City or town. state or province. country. and ZIP or foreign postal code Archer MSA O is being furnished to the Internal MA MSA O Revenue Service. Account number (see instructions) Form 1099-SA (keep for your records) vrww.ira.gov/forrn1099sa Department of the Treasury - Internal Revenue Service EFTA01222607