Instructions For Form 8853 - Archer Msas And Long-Term Care Insurance Contracts - 2001 Page 3
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8Line 5 Limitation Worksheet
Line 6
Go through this chart for each month of 2001.
Compensation
See the instructions for line 5.
(Keep for your records)
Compensation includes wages, salaries,
professional fees, and other pay you
Start Here
receive for services you perform. It also
includes sales commissions,
Were you eligible for Medicare
Yes
commissions on insurance premiums, pay
benefits for the month?
based on a percentage of profits, tips,
and bonuses. Generally, these amounts
No
are included on the Form(s) W-2 you
receive from your employer(s).
Compensation also includes net earnings
from self-employment, but only for a trade
Enter -0- on the line
Were you an eligible individual (see
No
or business in which your personal
below for the month.
page 1 of the instructions) on the
services are a material income-producing
first day of the month?
factor. Generally, this amount is shown on
the Schedule SE (Form 1040) you
Yes
complete for your business or farm.
Compensation does not include any
amounts received as a pension or annuity
and does not include any amount
What type of coverage did your HDHP provide on the first day of the
received as deferred compensation.
month? If you had more than one HDHP, see instructions.
Line 7
If you (or your employer) contributed
Self-only coverage
Family coverage
more to your Archer MSA than is
allowable, you may have to pay a tax on
Enter annual deductible
Enter annual deductible
excess contributions. Figure your excess
$
$
contributions using the instructions below.
See Form 5329, Additional Taxes on
Qualified Plans (Including IRAs) and
Other Tax-Favored Accounts, to figure
Enter 65% (.65) of the annual
Enter 75% (.75) of the annual
the additional tax.
deductible on the line below for the
deductible on the line below for the
month.
month. If married filing separately,
Excess Contributions You Make
see instructions.
To figure your excess contributions,
subtract your deductible contributions limit
(line 7) from your actual contributions (line
4). Do not include rollovers. However, you
Amount from
may withdraw some or all of your excess
Month in 2001
chart above
contributions for 2001 and they will be
treated as if they had not been
January
contributed if:
•
You make the withdrawal by the due
February
date, including extensions, of your 2001
March
tax return,
•
You do not claim a deduction for the
April
amount of the withdrawn contributions,
and
May
•
You also withdraw any income earned
June
on the withdrawn contributions and
include the earnings in “other income” on
July
your tax return for the year you withdraw
the contributions and earnings.
August
Excess Employer Contributions
September
Excess employer contributions are the
October
excess, if any, of your employer’s
contributions over the smaller of (a) your
November
limitation on line 5 or (b) your
compensation from the employer(s) who
December
maintained your HDHP. If the excess was
Total for all months
not included in income on Form W-2, you
must report it as “other income” on your
Limitation. Divide the total by 12. Enter here and on line 5
tax return. However, you may withdraw
some or all of the excess employer
contributions for 2001 and they will be
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