Understanding Form 1099-SA

The enclosed Form 1099-SA is for your PayFlex Health Savings Account (HSA). It shows your HSA distributions in 2015. This includes any purchases you made with your PayFlex debit card, direct payments to a health care provider and amounts paid to you from your HSA. PayFlex also sent a copy of this form to the Internal Revenue Service (IRS).

What do I need to do with Form 1099-SA?

Save it. You’ll use Form 1099-SA to complete IRS Form 8889 when you file your federal tax return. You can find more information on IRS Form 8889 at the bottom of this page.

What does the information on the form mean?

Below you’ll find a sample form with descriptions to help you understand the information. For more information, go to www.irs.gov.

SAMPLE Form 1099-SA

TRUSTEE’S/PAYER’S name, street address, city or town, state or province, country, ZIP or foreign postal code, and telephone number / OMB No. 1545-1517
20XX
Form 1099-SA / Distributions
From an HSA,
Archer MSA, or
Medicare Advantage
MSA
PAYER’S federal identification number / RECIPIENT’S identification number / 1 Gross distribution
$ / / Copy B
For
Recipient
This information
is being furnished to the Internal Revenue Service.
RECIPIENT’S name
Street address (including apt. no.)
City or town, state or province, country, and ZIP or foreign postal code / 3 Distribution code /
5 HSA
Archer
MSA
MA
MSA
Account number (see instructions)

Form 1099-SA (keep for your records) www.irs.gov/form1099sa Department of the Treasury – Internal Revenue Service

Descriptions

Gross distribution is the total amount withdrawn from your HSA during the year. This may include direct payments to a health care provider or amounts distributed to you. / FMV on date of death is the fair market value of the account. This is reported only if the account holder has died. Fair market value is the total value of the account on the date of death.
Earnings on excess cont. includes earnings on any excess contributions you withdrew from your HSA by the due date of your income tax return. It also includes interest or investment earnings that apply to the funds that you withdrew. For more information, see instructions in the enclosed Form 1099-SA. / This section shows the type of account reported on this form. Your 1099-SA from PayFlex will show the HSA box checked.
Distribution code identifies the type of distributions for your HSA:
1 = Normal distribution 4 = Death distribution other than code 6
2 = Excess contributions 5 = Prohibited transaction
3 = Disability / Account number is the unique number that PayFlex assigned to your HSA.

For details on each distribution type, go to www.irs.gov.

IRS Form 8889 – Complete it when you file your federal tax return

As an HSA accountholder, you’ll need to complete IRS Form 8889 when you file your federal tax return.You’ll need to report your HSA contributions and withdrawals on this form.You can find your withdrawal amount on your 1099-SA; it’s listed under “Gross distribution”.Your total contribution amount is on the PayFlex member website, in the Financial Center. You can find IRS Form 8889 and its instructions on the IRS website (www.irs.gov).

Form 5498-SA – Coming in May 2016

In May 2016, PayFlex will send you Form 5498-SA for your records. You don’t need to include this form when filing your taxes. PayFlex will send the form to the IRS for you. This form includes pretax contributions from your paycheck, any contributions you made on your own (post-tax), and any employer contributions. These are contributions posted to your HSA for 2015. You can make 2015 contributions from January 1, 2015 through the tax filing deadline. For 2015, the tax filing deadline is April 18, 2016.