Montana Form Msa Draft - Montana Medical Care Savings Account - 2011

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MONTANA

CLEAR FORM

MSA

Rev 06 11

2011 Montana Medical Care Savings Account

Annual Reporting Information for Self-Administered Accounts

15-61-202, MCA

Social Security Number

First Name and Initial

Last Name

Name and address of the ﬁ nancial institution where your Montana medical care savings account is established:

__________________________________________________________________________________________

Your Montana medical care savings account number:

Part I. Allowable Deduction Calculation

1. Current year deposits (Column A if using MSA-Worksheet) ....................... 1.

2. Deposits from prior years not previously deducted .................................... 2.

3. Add lines 1 and 2 ........................................................................................ 3.

4. Enter the lesser of the amount on line 3 or $3,000...................................................................4.

5. Interest and other income (Column B if using MSA-Worksheet) ..............................................5.

6. Add lines 4 and 5. This is your Montana Medical Saving Account exclusion. Enter this

amount on Form 2, Schedule II, line XX or Form 2M, line XX ..................................................6.

7. If the amount on line 3 is greater than $3,000, subtract line 4 from line 3.

These are your excess deposits which may be excluded next year.........................................7.

Part II. Nonqualiﬁ ed Withdrawals

1. Nonqualiﬁ ed withdrawals (Column D if using MSA-Worksheet) ...............................................1.

Enter this amount on Form 2, Schedule I, line XX or Form 2M, line XX

2. Enter the withdrawals on line 1 made on the last business day in December 2011 .................2.

3. Subtract line 2 from line 1 .........................................................................................................3.

4. Multiply the amount on line 3 by 10% (0.10). Enter this amount on Form 2, line XX or

Form 2M, line XX, and write “MSA” in the space provided. This is your penalty ......................4.

The Montana Medical Care Savings Account Worksheet (MSA-Worksheet) is available to help you reconcile the activity

on this form by providing a log to track expenses, deposits, withdrawals, fees, and other transactions. It is not required to

be completed or included with your tax return. (The MSA-Worksheet follows the instructions for this form.)

If you ﬁ le your Montana tax return electronically, you do not need to mail this form to us unless we ask you for a copy. When you ﬁ le electronically, you

represent that you have retained the required documents in your tax records and will provide them upon the department’s request.

*11DL0101*