Form 8853 - Archer Msas And Long-Term Care Insurance Contracts
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1
2OMB No. 1545-0074
8853
Archer MSAs and
2008
Form
Long-Term Care Insurance Contracts
Attachment
Department of the Treasury
Attach to Form 1040 or Form 1040NR.
See separate instructions.
39
Internal Revenue Service
(99)
Sequence No.
Name(s) shown on return
Social security number of MSA
account holder. If both spouses
have MSAs, see page 1 of the instructions
Section A.
Archer MSAs. If you have only a Medicare Advantage MSA, skip Section A and complete Section B.
Part I
General Information. See page 2 of the instructions.
Yes No
1a
1a Did you or your employer make contributions to your Archer MSA for 2008?
1b
b
If “Yes,” were you uninsured when the MSA was established (see page 2 of the instructions)?
c
If line 1a is “Yes,” indicate coverage under high deductible health plan:
Self-Only
or
Family
2a
2a
If married, did your spouse or spouse’s employer make contributions to your spouse’s Archer MSA for 2008?
b
If “Yes,” was your spouse uninsured when the MSA was established (see page 2 of the instructions)?
2b
c
If line 2a is “Yes,” indicate coverage under high deductible health plan:
Self-Only
or
Family
Part II
Archer MSA Contributions and Deductions. See page 2 of the instructions before completing this part.
If you are filing jointly and both you and your spouse have high deductible health plans with self-only
coverage, complete a separate Part II for each spouse.
3
3
Total employer contributions to your Archer MSA(s) for 2008
4
Archer MSA contributions you made for 2008, including direct deposits of economic stimulus
payments and those made from January 1, 2009, through April 15, 2009, that were for 2008. Do
4
not include rollovers (see page 3 of the instructions)
5
5
Limitation from the worksheet on page 3 of the instructions
6
Compensation (see page 3 of the instructions) from the employer maintaining the high deductible
health plan. (If self-employed, enter your earned income from the trade or business under which
the high deductible health plan was established.)
6
7
Archer MSA deduction. Enter the smallest of line 4, 5, or 6 here. Also include this amount on
Form 1040, line 36, or Form 1040NR, line 34. On the dotted line next to Form 1040, line 36, or
Form 1040NR, line 34, enter “MSA” and the amount.
7
Caution: If line 4 is more than line 7, you may have to pay an additional tax (see page 4 of the instructions).
Part III
Archer MSA Distributions
8a
8a Total distributions you and your spouse received in 2008 from all Archer MSAs (see page 4 of the instructions)
b
Distributions included on line 8a that you rolled over to another Archer MSA or a health savings
account. Also include any portion of a direct deposit of an economic stimulus payment and
excess contributions (and the earnings on those excess contributions) included on line 8a that
8b
were withdrawn by the due date of your return (see page 4 of the instructions)
8c
c
Subtract line 8b from line 8a
9
9
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, or Form 1040NR, line 21. On the dotted
10
line next to line 21, enter “MSA” and the amount
11a
If any of the distributions included on line 10 meet any of the Exceptions to the Additional
15% Tax (see page 5 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 additional 15% tax. Also include this amount in the total on
Form 1040, line 61, or Form 1040NR, line 57. On the dotted line next to Form 1040, line 61, or
Form 1040NR, line 57, enter “MSA” and the amount
11b
Section B. Medicare Advantage MSA Distributions. If you are filing jointly and both you and your spouse received
distributions in 2008 from a Medicare Advantage MSA, complete a separate Section B for each spouse
(see page 5 of the instructions).
12
12
Total distributions you received in 2008 from all Medicare Advantage MSAs (see page 5 of the instructions)
13
13
Unreimbursed qualified medical expenses (see page 6 of the instructions)
14
Taxable Medicare Advantage 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, or Form 1040NR, line 21.
14
On the dotted line next 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 Additional
50% Tax (see page 6 of the instructions), check here
b
Additional 50% tax (see page 6 of the instructions). Also include this amount in the total on
Form 1040, line 61, or Form 1040NR, line 57. On the dotted line next to Form 1040, line 61, or
Form 1040NR, line 57, enter “Med MSA” and the amount
15b
8853
Form
(2008)
For Paperwork Reduction Act Notice, see page 8 of the instructions.
Cat. No. 24091H
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