CUSTODIAN 1099-SA REPAIR WORKSHEET
Use this checklist to track the preparation and filing of a corrected Form 1099-SA.

Account Holder Name:
Account Number / Reference:
Original IRS Filing Status (Accepted/Rejected):

[ ] Verify original form was accepted by IRS.
[ ] Identify reason for correction (e.g., Mistaken Distribution, Death of Holder, TIN Error).
[ ] If mistaken distribution, verify receipt of beneficiary statement of reasonable cause.

DATA COMPARISON:
Box 1 Original Amount: ____________ Corrected Amount: ____________
Box 2 Original Amount: ____________ Corrected Amount: ____________
Box 3 Original Code:   ____________ Corrected Code:   ____________
Box 4 Original FMV:    ____________ Corrected FMV:    ____________

TRANSMISSION REVIEW:
[ ] Ensure CORRECTED box is checked on the new form.
[ ] Confirm the repayment is explicitly excluded from 5498-SA contribution staging.
[ ] Determine filing channel (IRIS vs Paper).
[ ] Transmit corrected record to the IRS.
[ ] IRS Transmission Receipt / Acknowledgment Date: ____________

FURNISHING:
[ ] Furnish Corrected Copy B to the account holder.
[ ] If recipient TIN truncation is used on Copy B, verify permitted masking; retain full payer TIN.
[ ] Save all audit documentation and ledger adjustments to the account profile.

Prepared By: _______________ Date: _______________
Approved By: _______________ Date: _______________