Form 8853 Long-Term Care Insurance Contracts
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1
28853
OMB No. 1545-1561
Archer MSAs and
2000
Form
Long-Term Care Insurance Contracts
Attachment
Department of the Treasury
39
Attach to Form 1040.
See separate instructions.
Sequence No.
Internal Revenue Service
Social security number of MSA
Name(s) shown on return
account holder. If both spouses
have MSAs, see page 1
Section A. Archer MSAs.
Note: Medical savings accounts (other than Medicare+Choice MSAs) are now called Archer MSAs.
If you have only a Medicare+Choice MSA, skip Section A and complete Section B.
Part I
General Information. See page 1 of the instructions.
Yes No
1a
1a
Did you or your employer make contributions to your Archer MSA for 2000?
1b
b
If “Yes,” were you uninsured when the MSA was established (see page 2 of the instructions)?
Family
c If line 1a is “Yes,” indicate coverage under high deductible health plan:
Self-Only
or
2a
2a
If married, did your spouse or spouse’s employer make contributions to your spouse’s Archer MSA for 2000?
2b
If “Yes,” was your spouse uninsured when the MSA was established (see page 2 of the instructions)?
b
c If line 2a is “Yes,” indicate coverage under high deductible health plan:
Family
Self-Only
or
Part II
Archer MSA Contributions and Deductions. See page 2 of the instructions before completing this part.
If you and your spouse each have high deductible health plans with self-only coverage, check here
If you check this box, complete a separate Part II for each spouse (see page 2 of the instructions).
3a
Were any employer contributions made to your Archer MSA(s) for 2000?
Yes
No
b
Enter all employer contributions to your Archer MSA(s) for 2000
4
Enter Archer MSA contributions that you made for 2000, including those made from January 1, 2001,
4
through April 16, 2001, that were for 2000. Do not include rollovers (see page 4 of the instructions)
5
5
Enter your limitation from the worksheet on page 3 of the instructions
6
Enter your compensation (see page 3 of the instructions) from the employer maintaining the high
deductible health plan. If you (and your spouse, if married filing jointly) have more than one plan,
see How To Complete Part II on page 2 of the instructions. (If self-employed, enter your earned
6
income from the trade or business under which the high deductible health plan was established.)
7
7
Archer MSA deduction. Enter the smallest of line 4, 5, or 6 here and on Form 1040, line 25
Note: If line 4 is more than line 7, you may have to pay an additional tax. See page 3 of the instructions for details.
Part III
Archer MSA Distributions
8a Enter the total Archer MSA distributions you and your spouse received in 2000 from all Archer
8a
MSAs (see page 4 of the instructions)
b
Enter any distributions included on line 8a that you rolled over to another Archer MSA (see page
4 of the instructions). Also include any excess contributions (and the earnings on those excess
8b
contributions) included on line 8a that were withdrawn by the due date of your return
8c
c
Subtract line 8b from line 8a
9
9
Enter your total unreimbursed qualified medical expenses (see page 4 of the instructions)
10
Taxable Archer MSA distributions. Subtract line 9 from line 8c. If zero or less, enter -0-. Also
include this amount in the total on Form 1040, line 21. On the dotted line next to line 21, enter
10
“MSA” and the amount
11a
If any of the distributions included on line 10 meet any of the Exceptions to the 15% Tax
(see page 4 of the instructions), check here
b
Additional 15% Tax (see page 4 of the instructions). Enter 15% (.15) of the distributions included
on line 10 that are subject to the 15% tax. Also include this amount in the total on Form 1040,
line 57. On the dotted line next to line 57, enter “MSA” and the amount
11b
Section B. Medicare+Choice MSA Distributions.
If you are married filing jointly and both you and your spouse received distributions in 2000 from a
Medicare+Choice MSA, complete a separate Section B for each spouse. See page 5 of the instructions.
12
12
Enter the total distributions you received in 2000 from all Medicare+Choice MSAs
13
13
Enter your total unreimbursed qualified medical expenses (see page 5 of the instructions)
14
Taxable Medicare+Choice MSA Distributions. Subtract line 13 from line 12. If zero or less,
enter -0-. Also include this amount in the total on Form 1040, line 21. On the dotted line next
14
to line 21, enter “Med+MSA” and the amount
15a
If any of the distributions included on line 14 meet any of the Exceptions to the 50% Tax
(see page 5 of the instructions), check here
b
Additional 50% Tax. See page 5 of the instructions. Also include this amount in the total on
Form 1040, line 57. On the dotted line next to line 57, enter “Med+MSA” and the amount
15b
8853
For Paperwork Reduction Act Notice, see page 8 of the instructions.
Cat. No. 24091H
Form
(2000)
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