2017 Health Savings Account 6768 Form 1099 SA & Instructions
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National Financial Services LLC
Agent for Fidelity Personal Trust Company
P.O. Box 28019
Albuquerque, NM 87125-8019
Federal ID Number: 04-3523567
SHANE MURRAY
804 SARATOGA AVE APT B315
SAN JOSE CA 95129-2565 Customer Service:800-544-3716
Visit Us Online:Fidelity.com
eDelivered
2017 Form 1099-SA Distributions from an HSA
Account No. Taxpayer ID. Page
219-996768 ***-**-4204 1 of 2
01/13/18 eDelivered
Form 1099-SA 2017 Distributions from an HSA
This information is being furnished to the Internal Revenue Service. OMB No.1545-1517
Copy B for Participant
1 Gross Distribution .................................................................... 198.16
2 Earnings on Excess Contributions ........................................................ 0.00
3 Distribution Code .......................................................................... 1
4 Fair Market Value on Date of Death ...................................................... 0.00
5 Account Type ............................................................................. HSA
731717.4.0
National Financial Services LLC
Agent for Fidelity Personal Trust Company
P.O. Box 28019
Albuquerque, NM 87125-8019
Federal ID Number: 04-3523567
Customer Service:800-544-3716
Visit Us Online:Fidelity.com
SHANE MURRAY
804 SARATOGA AVE APT B315
SAN JOSE CA 95129-2565
2017 Form 1099-SA Distributions from an HSA
Account No. Taxpayer ID. Page
219-996768 ***-**-4204 2 of 2
eDelivered
01/13/18 eDelivered
Form 1099-SA: Distributions from an HSA
These are IRS instructions that we are required to provide to you.
Instructions for Recipient
Distributions from a health savings account (HSA) are reported to you on
Form 1099-SA. File Form 8889, Health Savings Accounts (HSAs), with
your Form 1040 to report a distribution from these accounts even if the
distributionis not taxable.The payer is not requiredto compute the taxable
amount of any distribution.
An HSA distribution is not taxable if you used it to pay qualified medical
expenses of the account holder or eligible family member or you rolled it
over. An HSA may be rolled over to another HSA. If you did not use the
distribution from an HSA to pay for qualified medical expenses, or in the
case of an HSA, you did not roll it over, you must include the distributionin
your income (see Form 8889). Also, you may owe a penalty.
You may repay a mistaken distribution from an HSA no later than April 15
followingthe first year you knew or should haveknown the distributionwas
a mistaken, providing the trustee allows the repayment.
For more information, see the separate instructions for Form 8889. Also
see Pub. 969, Health Savings Accounts and Other Tax-Favored Health
Plans.
Recipient's identification number. For your protection, this form may
show only the last four digits of your social security number (SSN),
individual taxpayer identification number (ITIN), or adoption taxpayer
identification number (ATIN). However, the issuer has reported your
complete identificationnumber to the IRS, and, where applicable,to state
and/or local governments.
Spouse beneficiary. If you inherited an HSA because of the death of
your spouse, see the Instructions for Form 8889.
Estate beneficiary. If the HSA account holder dies and the estate is the
beneficiary, the fair market value (FMV) of the account on the date of
death is includible in the account holder's gross income. Report the
amount on the account holder's final income tax return.
Nonspousebeneficiary. If you inheritedthe HSA from someonewho was
not your spouse, you must report as incomeon your tax return the FMV of
the account as of the date of death. Report the FMV on your tax return for
the year the account owner died even if you receivedthe distribution from
the account in a later year.
See the Instructions for Form 8889. Any earnings on the account after
the date of death (line 1 minus line 4 of Form 1099-SA) are taxable.
Include the earnings on the "Other income" line on your tax return.
Account number. May show an account or other unique number the
payer assigned to distinguish your account.
Line 1. Shows the amount received this year. The amount may have
been a direct payment to the medical service provider or distributed to
you.
Line 2. Shows the earnings on any excess contributions you withdrew
from an HSA by the due date of your income tax return. If you withdrew
the excess, plus any earnings, by the due date of your income tax return,
you must include the earnings in your income in the year you received the
distribution even if you used it to pay qualified medical expenses. This
amount is included in line 1. Include the earnings on the "Other income"
line of your tax return. An excise tax of 6% for each tax year is imposed
on you for excess individualand employercontributionsthat remain in the
account. See Form 5329, AdditionalTaxes on QualifiedPlans (Including
IRAs) and Other Tax-Favored Accounts.
Line 3. These codes identify the distribution you received: 1-Normal
distribution; 2-Excess contributions; 3-Disability; 4-Death distribution
other than code 6; 5-Prohibited transaction; 6-Death distribution after
year of death to a nonspouse beneficiary.
Line 4. If the account holderdied, shows the FMV of the account on the
date of death.
Line 5. Shows the type of account that is reported on this Form
1099-SA.
Future developments. For the latest information about developments
relatedto Form 1099-SA and its instructions, such as legislationenacted
after the form and instructions were published, go to
www.irs.gov/form1099sa.
