This document is the 2019 IRS Form 1099‑SA (Copy B for Recipient) issued by UMB Bank N.A. to Pamela Esparza, reporting a $196.00 gross distribution from her Health Savings Account (HSA). The form lists payer and recipient details, the account number, distribution code (1 – normal distribution), and confirms that the information is being furnished to the IRS. Accompanying the form are detailed IRS instructions for the recipient, explaining how to report the distribution on Form 8853 or Form 8889, the taxability of HSA/Archer/MA MSA distributions, rules for rollovers, repayment of mistaken distributions, and special beneficiary rules (spouse, estate, non‑spouse). It also clarifies the meaning of each box on the form, the significance of distribution codes, and provides references to IRS publications and future updates.
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Recipient Identification and Distribution Summary
Payer (UMB Bank) and recipient (Pamela Esparza) details, account number, gross distribution amount, and distribution code.