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ri VOID n CORRECTED TRUSTEE &PAYER S name. street address. city or town. state or province. country. ZIP or foreign postal code. and telephone number JI O0.18 No. 1545-1517 2018 Form 1099-SA Distributions From an HSA, Archer MSA, or Medicare Advantage MSA PAYER'S TIN RECIPIENT'S TIN 1 Gross distribution 2 Earnings on excess cont. Copy A For Internal Revenue Service Center File with Form 1096. For Privacy Act and Paperwork Reduction Act Notice. see the 2018 General Instructions for Certain Information Returns. RECIPIENT'S name 3 Distribution code 4 FMV on date of death $ Street address (including apt. no.) S HSA Archer MSA K MA MSA City or town. state or province. country. and ZIP or foreign postal code Account number (see instructions) Form 1099-SA vmw.irs.gowForm1099SA Department of the Treasury - Internal Revenue Service EFTA01222608