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Archer MSA for you or your spouse for

Line 5 Limitation Chart and Worksheet

2005. These contributions should be

Go through this chart for each month of 2005.

shown in box 12 of Form W-2 with code

See the instructions for line 5 on this page.

R. If your employer made excess

(Keep for your records)

contributions, you may have to report the

excess as income. See Excess Employer

Start Here

Contributions on page 4 for details.

Were you enrolled in Medicare for

Line 4

Yes

the month?

Do not include amounts rolled over from

another Archer MSA. See Rollovers on

page 4.

Line 5

Go through the chart at the top of the Line

Were you an eligible individual (see

Enter -0- on the line

5 Limitation Chart and Worksheet on this

below for the month.

page 1 of the instructions) on the

page for each month of 2005. Enter the

first day of the month?

result on the worksheet next to the

corresponding month.

Yes

If eligibility and coverage of both

you and your spouse did not

TIP

change from one month to the

What type of coverage did your HDHP provide on the first day of the

next, enter the same number you entered

month? If you had more than one HDHP, see instructions on this page.

for the previous month. If eligibility and

coverage did not change during the entire

year, figure the number for January only,

Self-only coverage

Family coverage

and enter this amount on Form 8853, line

Enter annual deductible

(must be at least $1,750

(must be at least $3,500

More than one HDHP. If you and your

but not more than $2,650)

but not more than $5,250)

spouse had more than one HDHP on the

first of the month and one of the plans

provides family coverage, use the Family

coverage rules on the chart and disregard

Enter 65% (.65) of the annual

Enter 75% (.75) of the annual

any plans with self-only coverage. If you

deductible on the line below for the

and your spouse both have HDHPs with

month.

month. If married filing separately,

family coverage on the first of the month,

see instructions on this page.

you both are treated as having only the

family coverage plan with the lowest

annual deductible.

Amount from

Married filing separately. If you have an

Month in 2005

chart above

HDHP with family coverage and are

married filing separately, enter only

January

37.5% (.375) (one-half of 75%) of the

annual deductible on the worksheet; or, if

February

you and your spouse agree to divide the

March

75% of the annual deductible in a

different manner, enter your share.

April

Line 6

May

Compensation

June

Compensation includes wages, salaries,

July

professional fees, and other pay you

receive for services you perform. It also

August

includes sales commissions,

September

commissions on insurance premiums, pay

based on a percentage of profits, tips,

October

and bonuses. Generally, these amounts

are included on the Form(s) W-2 you

November

receive from your employer(s).

December

Compensation also includes net earnings

from self-employment, but only for a trade

Total for all months

or business in which your personal

services are a material income-producing

Limitation. Divide the total by 12. Enter here and on line 5

factor. Generally, this amount is shown on

the Schedule SE (Form 1040) you

complete for your business or farm.

Compensation does not include any

amounts received as a pension or annuity

-3-

Instructions For Form 8853 - Archer Msas And Long-Term Care Insurance Contracts - 2005 Page 3

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