IRS 1099‑SA HSA Distribution Form – Fillable PDF

The IRS Form 1099‑SA is the official tax document used to report distributions from a Health Savings Account (HSA), Archer MSA, or Medicare Advantage MSA. Whether you took a qualified medical expense withdrawal or a non‑qualified distribution, the information must be reported to the IRS and to the account holder.

Formize provides a fillable PDF version of the 1099‑SA so you can complete it online, save a copy, and print or email it directly to the IRS—no additional PDF editor required.

What Is the 1099‑SA HSA Distribution Form?

The 1099‑SA captures the total amount distributed from your HSA during the tax year, the taxable portion, and any earnings that must be reported as income. The form is issued by the HSA trustee (bank, credit union, or other custodian) and must be attached to your individual tax return (Form 1040).

How to Fill Out the Form Using Formize

Instead of downloading the PDF and opening it in a separate editor, simply click the "Fill out this form" button on this page. The Formize PDF Filler app will load in your browser, letting you type directly into each field.

Common Mistakes & Tips for Accurate Filing

• Incorrect payer information – double‑check the trustee’s name, address, and EIN.
• Mis‑classifying qualified vs. non‑qualified withdrawals – only qualified medical expenses are tax‑free.
• Leaving Box 2 (Taxable amount) blank – the IRS requires this even if the amount is $0.
• Using the wrong tax year – the form must reflect the calendar year in which the distribution occurred.

Where to Submit the Completed 1099‑SA

After you finish the form in Formize, you can:

• Download a PDF copy for your records.
• Print and mail it to the IRS with your Form 1040.
• Email the PDF to your HSA trustee if they accept electronic submissions.

Always keep a copy for your personal files in case the IRS requests additional documentation.