Form 1099-SA Preparation & QA Checklist
[ ] Tax Year of Reporting:
[ ] Custodian/Issuer TIN Verified:

Account Identification:
[ ] Account Holder Name / Beneficiary Name matches system record.
[ ] Account Type verified (HSA, Archer MSA, or MA MSA).
[ ] Box 5 Checkbox mapped correctly to Account Type.

Financial Aggregation:
[ ] Box 1 Gross Distribution calculated correctly.
[ ] Excluded trustee-to-trustee transfers from total.
[ ] Excluded repaid mistaken distributions from total.
[ ] If excess contribution return, calculated Box 2 earnings.
[ ] Confirmed Box 2 earnings are included in Box 1 total.

Code Assignment (Box 3):
[ ] Code 1: Normal distribution / spouse payout after year of death.
[ ] Code 2: Excess contribution return (review applicable earnings in Box 2).
[ ] Code 3: Disability status confirmed on file.
[ ] Code 4: Estate payout, or nonspouse payout in year of death.
[ ] Code 5: Prohibited transaction documented.
[ ] Code 6: Nonspouse payout after year of death.

Death Processing:
[ ] If Account Holder deceased, Date of Death documented:
[ ] Box 4 FMV and any applicable later-year adjustment reviewed.
[ ] Date death learned and reporting-year rule verified.

Reviewer Sign-off:
[ ] Date of QA: