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Archer MSA for 2001, including

Your compensation from the employer

the two statement Forms 8853 to your

contributions for 2001 made from January

maintaining the HDHP (line 6).

return after the controlling Form 8853.

1, 2002, through April 15, 2002.

Any employer contributions made to

Lines 3a and 3b

Otherwise, check the “No” box on line 1a.

your Archer MSA prevent you from

making deductible contributions. You may

Check the “Yes” box on line 2a if you

Employer Contributions

not deduct any contributions you made

are filing a joint return and your spouse

after you became eligible for Medicare

Employer contributions include any

(or your spouse’s employer) made

benefits. Also, if you or your spouse made

amount an employer contributes to any

contributions to your spouse’s Archer

contributions in addition to any employer

Archer MSA for you or your spouse for

MSA for 2001, including contributions for

contributions, you may have to pay an

2001. These contributions should be

2001 made from January 1, 2002,

additional tax. See Excess

shown in box 12 of Form W-2 with code

through April 15, 2002. Otherwise, check

Contributions You Make on page 3.

R. See Excess Employer Contributions

the “No” box on line 2a.

on page 3 for details.

Employer Contributions to an

Lines 1b and 2b

Archer MSA

Line 4

Check “Yes” on line 1b or 2b only if the

If an employer made contributions to your

account holder is considered previously

Do not include amounts rolled over from

Archer MSA, you are not entitled to a

uninsured. If an account holder has

another Archer MSA. See Rollovers on

deduction. If you and your spouse are

self-only coverage under an HDHP and

page 4.

covered under an HDHP with family

did not have any health plan coverage at

Line 5

coverage and an employer made

any time during the 6-month period before

Use the worksheet on page 3 to figure

contributions to either of your Archer

coverage under the HDHP began, the

your limitation.

MSAs, neither you nor your spouse are

account holder is considered previously

allowed to make deductible contributions

uninsured. In addition, for the account

Instructions for Line 5

to an Archer MSA. If you and your spouse

holder to be considered previously

Limitation Worksheet

each have an Archer MSA with self-only

uninsured, the HDHP coverage must not

Go through the chart for each month of

coverage and only one of you received

have begun before July 1, 1996.

2001. Enter the result on the

employer contributions to an Archer MSA,

If an account holder has family

corresponding line next to the month on

the other spouse is allowed to make

coverage under an HDHP and neither

the worksheet.

deductible contributions to an Archer

the account holder nor the account

MSA.

If eligibility and coverage of both

holder’s spouse had any health plan

you and your spouse did not

TIP

How To Complete Part II

coverage at any time during the 6-month

change from one month to the

period before coverage under the HDHP

Complete lines 3a through 7 as instructed

next, enter the same number you entered

began, the account holder is considered

on the form unless 1 or 2 below applies.

for the previous month. If eligibility and

previously uninsured. In addition, for the

1. If employer contributions to an

coverage did not change during the entire

account holder to be considered

Archer MSA prevent you from taking a

year, figure the number for January only,

previously uninsured, the HDHP coverage

deduction for amounts you contributed to

and enter this amount on line 5 of Form

must not have begun before July 1, 1996.

your Archer MSA, complete Part II as

8853.

In determining whether an account

follows.

More than one HDHP. If you (and your

holder is previously uninsured, disregard

a. Complete lines 3a through 4.

spouse, if married filing jointly) had more

any health insurance that is permitted in

b. Skip lines 5 and 6.

than one HDHP on the first of the month

addition to the HDHP. See Other Health

c. Enter -0- on line 7.

and one of the plans provides family

Insurance on page 1.

d. If line 4 is more than zero, see

coverage, use the Family coverage rules

Lines 1c and 2c

Excess Contributions You Make and

and disregard any plans with self-only

Excess Employer Contributions on

coverage.

If covered by a self-only HDHP and a

page 3.

family HDHP, indicate which plan was in

Self-only coverage. Enter the annual

2. If you and your spouse have more

effect longer during the year.

deductible, which must be at least $1,600

than one Archer MSA, complete lines 3a

but not more than $2,400. Enter 65%

Part II—Archer MSA

through 7 as follows.

(.65) of the annual deductible on the

a. If either spouse has an HDHP with

worksheet.

Contributions and

family coverage, complete lines 3a

Family coverage. Enter the annual

Deductions

through 7 using the Family coverage

deductible, which must be at least $3,200

rules in the instructions for line 5.

but not more than $4,800. Enter 75%

Use Part II to figure:

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b. If both spouses have HDHPs with

(.75) of the annual deductible on the

Your Archer MSA deduction and, if

self-only coverage, check the box in the

worksheet.

applicable, any excess contributions you

heading for Part II. Complete a separate

made and

However, if you have an HDHP with

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Form 8853, Section A, Part II, for each

Any excess contributions made by an

family coverage and are married filing

spouse. Write “statement” across the top,

employer (see Excess Employer

separately, enter only 37.5% (.375)

fill in the name and SSN, and complete

Contributions on page 3).

(one-half of 75%) of the annual deductible

Part II. Next, add the totals for lines 3b, 4,

on the worksheet; or, if you and your

Figuring Your Archer MSA

and 7 from the two separate statement

spouse agree to divide the 75% of the

Deduction

Forms 8853 and enter those totals on the

annual deductible in a different manner,

respective lines of the controlling Form

The amount you may deduct for Archer

enter your share.

8853 (the combined Form 8853 for both

MSA contributions is limited by:

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spouses). Do not complete lines 3a, 5,

The applicable portion of the policy’s

and 6 of the controlling Form 8853. Attach

annual deductible (line 5) and

-2-

Instructions For Form 8853 - Archer Msas And Long-Term Care Insurance Contracts - 2001 Page 2

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