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written at the top. Report any related

explanation of the withdrawal. Make

earnings for 2011 on the amended

any other necessary changes on the

return and include an explanation of the

amended return (for example, if you

withdrawal. Make any other necessary

reported the contributions as excess

changes on the amended return (for

contributions on your original return,

example, if you reported the

include an amended Form 5329

contributions as excess contributions

reflecting that the withdrawn

on your original return, include an

contributions are no longer treated as

amended Form 5329 reflecting that the

having been contributed).

withdrawn contributions are no longer

treated as having been contributed).

Part VI—Additional Tax

treated as having been contributed).

Part VII—Additional Tax

on Excess Contributions

Part V—Additional Tax

on Excess Contributions

to Archer MSAs

on Excess Contributions

to Health Savings

If you or your employer contributed

to Coverdell ESAs

Accounts (HSAs)

more to your Archer MSA for 2011 than

If the contributions to your Coverdell

is allowable or you had an amount on

If you, someone on your behalf, or your

line 41 of your 2010 Form 5329, you

ESAs for 2011 were more than is

employer contributed more to your

may owe this tax. But you may be able

allowable or you had an amount on line

HSAs for 2011 than is allowable or you

33 of your 2010 Form 5329, you may

to avoid the tax on any 2011 excess

had an amount on line 49 of your 2010

contributions (see the instructions for

owe this tax. But you may be able to

Form 5329, you may owe this tax. But

line 39, later).

avoid the tax on any 2011 excess

you may be able to avoid the tax on

contributions (see the instructions for

Line 34

any 2011 excess contributions (see the

line 31, later).

instructions for line 47, later).

Enter the amount from line 40 of your

Line 26

2010 Form 5329 only if the amount on

Line 43

line 41 of your 2010 Form 5329 is more

Enter the amount from line 32 of your

If your contribution limit for your HSAs

than zero.

2010 Form 5329 only if the amount on

(line 12 of Form 8889, Health Savings

line 33 of your 2010 Form 5329 is more

Line 35

Accounts (HSAs)) is greater than the

than zero.

contributions you made to your HSAs

If your contribution limit for your Archer

Line 27

(or those made on your behalf) for 2011

MSAs (the smaller of line 3 or line 4 of

(Form 8889, line 2), enter the difference

Form 8853, Archer MSAs and

Enter the excess, if any, of the

on line 43. Also include on your 2011

Long-Term Care Insurance Contracts)

maximum amount that can be

Form 8889, line 13, the smaller of:

is greater than the contributions to your

contributed to your Coverdell ESAs for

•

Form 5329, line 43, or

Archer MSAs for 2011, enter the

2011 (see the instructions for line 31

•

The excess, if any, of Form 5329,

difference on line 35. Also include on

below) over the amount actually

line 42, over Form 5329, line 44.

your 2011 Form 8853, line 5, the

contributed for 2011.

smaller of:

Line 47

Line 28

•

Form 5329, line 35, or

•

Enter the excess of your contributions

The excess, if any, of Form 5329,

Enter your total distributions from

(including those made on your behalf)

line 34, over Form 5329, line 36.

Coverdell ESAs in 2011. Do not include

to your HSAs for 2011 (Form 8889, line

rollovers or returned excess

Line 39

2) over your contribution limit (Form

contributions.

8889, line 12). Also include on line 47

Enter the excess of your contributions

Line 31

any excess contributions your employer

to your Archer MSA for 2011 (from

made. See the instructions for Form

Form 8853, line 2) over your

Enter the excess of the contributions to

8889 for details.

contribution limit (the smaller of line 3 or

your Coverdell ESAs for 2011 (not

line 4 of Form 8853). Also include on

However, you can withdraw some or

including rollovers) over your

line 39 any excess contributions your

all of the excess contributions for 2011

contribution limit for Coverdell ESAs.

employer made. See the Instructions

Your contribution limit is the smaller of

and they will not be treated as having

for Form 8853 for details.

been contributed if:

$2,000 or the sum of the maximum

•

You make the withdrawal by the due

amounts allowed to be contributed by

However, you can withdraw some or

the contributor(s) to your Coverdell

date, including extensions, of your 2011

all of the excess contributions for 2011

return, and

ESAs. The maximum contribution may

and they will not be treated as having

•

You withdraw any income earned on

be limited based on the contributor’s

been contributed if:

•

the withdrawn contributions and include

modified AGI. See Pub. 970 for details.

You make the withdrawal by the due

the earnings in gross income for the

date, including extensions, of your 2011

You can withdraw some or all of the

year in which you receive the withdrawn

tax return, and

excess contributions for 2011 and they

•

contributions and earnings.

You withdraw any income earned on

will not be treated as having been

the withdrawn contributions and include

contributed if:

Include the withdrawn contributions

•

the earnings in gross income for the

and related earnings on Form 8889,

You make the withdrawal before

year in which you receive the withdrawn

June 1, 2012, and

lines 14a and 14b.

•

contributions and earnings.

You also withdraw any income

If you timely filed your return without

earned on the withdrawn contributions

Include the withdrawn contributions

withdrawing the excess contributions,

and include the earnings in gross

and related earnings on Form 8853,

you can still make the withdrawal no

income for the year in which the

lines 6a and 6b.

later than 6 months after the due date

contribution was made.

If you timely filed your return without

of your tax return, excluding extensions.

If you filed your return without

withdrawing the excess contributions,

If you do, file an amended return with

withdrawing the excess contributions,

you can still make the withdrawal no

“Filed pursuant to section 301.9100-2”

you can still make the withdrawal, but it

later than 6 months after the due date

written at the top. Report any related

must be made before June 1, 2012. If

of your tax return, excluding extensions.

earnings for 2011 on the amended

you do, file an amended return. Report

If you do, file an amended return with

return and include an explanation of the

any related earnings for 2011 on the

“Filed pursuant to section 301.9100-2”

withdrawal. Make any other necessary

amended return and include an

written at the top. Report any related

changes on the amended return (for

-5-

Instructions for Form 5329 (2011)

Instructions For Form 5329 - Additional Taxes On Qualified Plans And Other Tax-Favored Accounts - 2011 Page 5

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