Alex Morton is a single taxpayer, age 34. She is part of a qualifying high-deductible health plan. In 2019, Alex made contributions of $2,700 to her HSA. Alex's employer reported making $300 of contributions to her HSA in Box 12 of her Form W-2 (code W). Alex spent $2,500 on qualified medical expenses. Alex received the following Form 1099-SA from her HSA administrator:

◻ CORRECTED (if checked)

TRUSTEE'S/PAYER'S name, street address, city or town, state or province, country, ZIP or foreign postal code, and telephone number

Heritage Health Partners
PO Box 12345
Dallas, TX 75621

OMB No. 1545-1517

2019

Form 1099-SA

Distributions
From an HSA,
Archer MSA, or
Medicare Advantage
MSA

PAYER'S TIN

13-0080072

RECIPIENT'S TIN

213-21-3121

1 Gross distribution
$1,783.00

2 Earnings on excess cont.
$

Copy B
For Recipient


This information is being furnished to the IRS.

RECIPIENT'S name
Alex Morton
Street address (including apt. no.)
1921 S. Orange Ave.
City or town, state or province, country, and ZIP or foreign postal code
Orlando, FL 32806

3 Distribution code

1

4 FMV on date of death
$

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

Prepare Form 8889 to determine Alex's HSA deduction and taxable HSA distribution.
Enter all amounts as positive numbers. If an amount is zero, enter "0".

Form 8889 Department of the Treasury Internal Revenue Service	Health Savings Accounts (HSAs) ► Attach to Form 1040, 1040-SR, or 1040-NR. ► Go to www.irs.gov/Form8889 for instructions and the latest information.	OMB No. 1545-0074
		2019 Attachment Sequence No. 52

Name(s) shown on Form 1040, 1040-SR, or 1040-NR Alex Morton	Social security number of HSA beneficiary. If both spouses have HSAs, see instructions ►	213-21-3121
Before you begin: Complete Form 8853, Archer MSAs and Long-Term Care Insurance Contracts, if required.

Part I	HSA Contributions and Deduction. See the instructions before completing this part. If you are filing jointly and both you and your spouse each have separate HSAs, complete a separate Part I for each spouse.

1	Check the box to indicate your coverage under a high-deductible health plan (HDHP) during 2019 (see instructions) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .			►	Self-only
2	HSA contributions you made for 2019 (or those made on your behalf), including those made from January 1, 2020, through April 15, 2020, that were for 2019. Do not include employer contributions, contributions through a cafeteria plan, or rollovers (see instructions) . . . . . . . . . . . . . . . . . . . . . . . .				2
3	If you were under age 55 at the end of 2019 and, on the first day of every month during 2019, you were, or were considered, an eligible individual with the same coverage, enter $3,500 ($7,000 for family coverage). All others, see the instructions for the amount to enter . . . . . . . . . . . . . . . . . . . . .				3
4	Enter the amount you and your employer contributed to your Archer MSAs for 2019 from Form 8853, lines 1 and 2. If you or your spouse had family coverage under an HDHP at any time during 2019, also include any amount contributed to your spouse's Archer MSAs . . . . . . . . . . . . . . . . . . . . . . . . . . .				4
5	Subtract line 4 from line 3. If zero or less, enter -0- . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .				5
6	Enter the amount from line 5. But if you and your spouse each have separate HSAs and had family coverage under an HDHP at any time during 2019, see the instructions for the amount to enter . . . .				6
7	If you were age 55 or older at the end of 2019, married, and you or your spouse had family coverage under an HDHP at any time during 2019, enter your additional contribution amount (see instructions)				7
8	Add lines 6 and 7 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .				8
9	Employer contributions made to your HSAs for 2019 . . . . . . . . . . . .	9
10	Qualified HSA funding distributions . . . . . . . . . . . . . . . . . . . . . . . . .	10
11	Add lines 9 and 10 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .				11
12	Subtract line 11 from line 8. If zero or less, enter -0- . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .				12
13	HSA deduction. Enter the smaller of line 2 or line 12 here and on Schedule 1 (Form 1040 or 1040-SR), line 12, or Form 1040-NR, line 25 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .