n CORRECTED (if checked)

n CORRECTED (if checked) TRUSTEE'S/PAYER'S name. street address. city or town. state or province. coixtry. ZIP or foreign postal code. and telephone number PAYER'S federal identification number RECIPIENT'S identification number 1 Gross dtstnbution OMB No.1545-1517 2017 Form 1099-SA 2 Earnings on excess cont. $ 4 FMV on date of death Distributions From an HSA, Archer MSA, or Medicare Advantage MSA RECIPIENT'S name Street address (including apt. no.) City or town. state or province. country. and ZIP or foreign postal code 3 Distribution code $ S HSA Archer MSA MA MSA O O O Account number (see instructions) Copy B For Recipient This information is being furnished to the Internal Revenue Service. Form 1099-SA (keep for your records) vrww.ira.gov/forrn1099sa Department of the Treasury - Internal Revenue Service EFTA01222607