| Field Name | Size | Type | Description | Notes |
|---|
| See Form Filer Common Fields | Filer fields common to all form types. |
|
| See Recipient Common Fields | Recipient fields common to all form types. |
|
| Box 1 Amount | 12 | Amount | Gross distribution |
|
| Box 2 Amount | 12 | Amount | Earnings on excess contributions |
|
| Box 3 Code | 1 | Numeric | Distribution code | 1, 2, 3, 4, 5, 6 |
| Box 4 Amount | 12 | Amount | FMV on date of death |
|
| Box 5 Checkbox 1 | 1 | Checkbox | HSA | X / Y / T / 1 = Checked |
| Box 5 Checkbox 2 | 1 | Checkbox | Archer MSA | X / Y / T / 1 = Checked |
| Box 5 Checkbox 3 | 1 | Checkbox | MA MSA | X / Y / T / 1 = Checked |
| See Form Common Fields | Form fields common to all form types. |
|
