Form Tc-675m - Statement Of Withholding For Utah Medical Savings Account (Msa)

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Statement of Withholding
TC-675M
Date:__________________________
For Utah Medical Savings Account (MSA)
Rev. 12/98
1 Account holder's name, address, and social security number
4 Beginning balance in MSA plan
$
+
5 Amount contributed to plan
6 Plan earnings
+
7 Qualified medical distributions
-
2 Employer's name, address, and federal ID number
-
8 Non-medical distributions (not subject to penalties)
9 Non-medical distributions (subject to penalties*)
-
10 Administration fees
-
3 Account administrator's name, address, and federal ID number
11 Ending balance in MSA plan
$
=
12 * Penalties for non-medical distributions
$

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