This document is a Copy B of IRS Form 1099‑SA reporting a distribution of $1,076.14 from a Health Savings Account (HSA) held by Pamela Esparza‑Hernandez. The payer/trustee is UMB Bank N.A., located in Kansas City, MO. The form lists the recipient’s address, taxpayer identification numbers (partially redacted), account number, and distribution code (1 – normal distribution). The HSA box is checked, indicating the account type. The accompanying instructions explain how the distribution should be reported on Form 8889 or Form 8853, when it is taxable, the rules for rollovers, repayment of mistaken distributions, and the tax treatment for various beneficiary scenarios (spouse, estate, non‑spouse). Detailed explanations of each box on the form (Boxes 1‑5) are provided, along with references to IRS publications and future updates.
Topics
Recipient and Distribution Summary
Key identifying information for the recipient (name, address, TIN) and the core financial data (gross distribution amount, account number, distribution code).
Payer/Trustee Identification and Compliance Details
Information about the payer (UMB Bank N.A.), including address, phone number, and TIN, establishing the source of the distribution and compliance with IRS reporting requirements.
Tax Reporting Instructions for HSA Distributions
Guidance on filing Form 8889 or Form 8853 with the 1040, criteria for taxable vs. non‑taxable distributions, rollover rules, and penalties for improper use.
Beneficiary Scenarios and Tax Implications
Explanation of how different beneficiary types (spouse, estate, non‑spouse) affect the tax treatment of the distribution and any required reporting of fair market value.
Box‑by‑Box Explanation of Form 1099‑SA
Detailed description of each box on the form (Boxes 1‑5), including what they represent, how amounts are calculated, and related tax consequences.