Montana Form Msa - Montana Medical Care Savings Account - 2009
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1MONTANA
MSA
Clear Form
Rev. 07-09
2009 Montana Medical Care Savings Account
Annual Reporting Information for Self-Administered Accounts
15-61-202, MCA
Enter your name here (as it appears on your tax return): _____________________________________________
Enter your social security number here: __________________________________________________________
Enter the name and address of the fi nancial institution where your Montana medical care savings account is established:
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
Enter your Montana medical care savings account number here _______________________________________
Complete the table below reporting the 2009 activity to your Montana medical care savings account.
Column A
Column B
Column C
Column D
Column E
Column F
Enter the date
Enter the amount
Enter the amount
Enter your
Enter your
Balance – Add
of your deposits,
of your deposits
of interest or
“eligible medical
“non-qualifi ed”
the amounts in
earnings, or
to your Montana
other income
expense”
withdrawals.
columns B and
withdrawals.
medical care
earned on your
withdrawals.
C, then subtract
savings account.
Montana medical
from this total
care savings
any amounts
account.
reported in
Columns D and
E. Enter the
result.
1. Enter in column F the balance of your Montana medical care savings account as of January
1, 2009. This is the ending balance of your Montana medical care savings account as of
December 31, 2008. If you established your account in 2009 enter zero here as your beginning
balance is established on the date of your fi rst deposit.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14. Enter the column
totals on this line.
If you have an amount entered in line 14, column E enter it here and on
Form 2, Schedule I, line 7, or Form 2M, line 25. Complete Form MSA-P
(Penalty Calculation) if required.
Enter the ending balance reported in column F. This is your balance that is carried forward to
2010.
127
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