Instructions For Form 8853 - 2009 (Page 2 of 8) in pdf

Death of Account Holder

expenses. Generally, these distributions

a. If either spouse has an HDHP with

are subject to the additional 15% tax.

family coverage, you both are treated as

If the account holder’s surviving spouse is

having only the family coverage plan.

the designated beneficiary, the Archer

Part I—Archer MSA

Disregard any plans with self-only

MSA is treated as if the surviving spouse

coverage.

were the account holder. The surviving

Contributions and

b. If both spouses have HDHPs with

spouse completes Form 8853 as though

Deductions

family coverage, you both are treated as

the Archer MSA belonged to him or her.

having only the family coverage plan with

Use Part I to figure:

If the designated beneficiary is not the

the lowest annual deductible.

•

Your Archer MSA deduction,

account holder’s surviving spouse, or

c. If both spouses have HDHPs with

•

Any excess contributions you made,

there is no designated beneficiary, the

self-only coverage, complete a separate

and

account ceases to be an Archer MSA as

Form 8853, Section A, Part I, for each

•

Any excess contributions made by an

of the date of death. The beneficiary

spouse. Enter “statement” across the top

employer (see Excess Employer

completes Form 8853 as follows.

of each Form 8853, fill in the name and

•

Contributions on page 3).

Enter “Death of Archer MSA account

SSN, and complete Part I. Next, add lines

holder” across the top of Form 8853.

Figuring Your Archer MSA

1, 2, and 5 from the two statement Forms

•

Enter the name(s) shown on your tax

8853 and enter those totals on the

Deduction

return and your SSN in the spaces

respective lines of the controlling Form

The amount you can deduct for Archer

provided at the top of the form and skip

8853 (the combined Form 8853 for both

MSA contributions is limited by:

Part I.

spouses). Do not complete lines 3 and 4

•

The applicable portion of the HDHP’s

On lines 6a and 6c, enter the fair

of the controlling Form 8853. Attach the

annual deductible (line 3), and

market value of the Archer MSA as of the

•

two statement Forms 8853 to your tax

Your compensation from the employer

date of death.

return after the controlling Form 8853.

•

maintaining the HDHP (line 4).

On line 7, for a beneficiary other than

Any employer contributions made to

the estate, enter qualified medical

Line 1

your Archer MSA prevent you from

expenses incurred by the account holder

making deductible contributions. See

before the date of death that you paid

Employer Contributions

Employer Contributions to an Archer MSA

within 1 year after the date of death.

Employer contributions include any

•

below. Also, if you or your spouse made

Complete the rest of Part II.

amount an employer contributes to any

contributions in addition to any employer

Archer MSA for you or your spouse for

If the account holder’s estate is the

contributions, you may have to pay an

2009. These contributions should be

beneficiary, the value of the Archer MSA

additional tax. See Excess Contributions

shown in box 12 of Form W-2 with code

as of the date of death is included in the

You Make on page 3.

R. If your employer made excess

account holder’s final income tax return.

You cannot deduct any contributions

contributions, you may have to report the

Complete Form 8853 as described above,

you made after you became enrolled in

excess as income. See Excess Employer

except you should complete Part I, if

Medicare. Also, you cannot deduct

Contributions on page 3 for details.

applicable.

contributions if you can be claimed as a

Line 2

The distribution is not subject to the

dependent on someone else’s 2009 tax

additional 15% tax. Report any earnings

return.

Include on line 2 contributions you made

on the account after the date of death as

to your MSA. Also include those

Employer Contributions to an

income on your tax return.

contributions made from January 1, 2010,

Archer MSA

through April 15, 2010, that were for

Note. If, during the tax year, you are the

If an employer made contributions to your

2009. Do not include amounts rolled over

beneficiary of 2 or more Archer MSAs or

Archer MSA, you are not entitled to a

from another Archer MSA. See Rollovers

you are a beneficiary of an Archer MSA

deduction. If you and your spouse are

on page 4.

and you have your own Archer MSA, you

covered under an HDHP with family

must complete a separate Form 8853 for

Line 3

coverage and an employer made

each MSA. Enter “statement” at the top of

contributions to either of your Archer

Go through the chart at the top of the Line

each Form 8853 and complete the form

MSAs, neither you nor your spouse are

3 Limitation Chart and Worksheet on

as instructed. Next, complete a controlling

allowed to make deductible contributions

page 3 for each month of 2009. Enter the

Form 8853, combining the amounts

to an Archer MSA. If you and your spouse

result on the worksheet next to the

shown on each of the statement Forms

each have an HDHP with self-only

corresponding month.

8853. Attach the statements to your tax

coverage and only one of you received

return after the controlling Form 8853.

If eligibility and coverage of both

employer contributions to an Archer MSA,

TIP

you and your spouse did not

the other spouse is allowed to make

Deemed Distributions From Archer

change from one month to the

deductible contributions to an Archer

MSAs

next, enter the same number you entered

MSA.

The following situations result in deemed

for the previous month. If eligibility and

How To Complete Part I

coverage did not change during the entire

distributions from your Archer MSA.

•

year, figure the number for January only,

You engaged in any transaction

Complete lines 1 through 5 as instructed

and enter this amount on Form 8853, line

prohibited by section 4975 with respect to

on the form unless 1 or 2 below applies.

any of your Archer MSAs, at any time in

1. If employer contributions to an

2009. Your account ceases to be an

More than one HDHP. If you and your

Archer MSA prevent you from taking a

Archer MSA as of January 1, 2009, and

deduction for amounts you contributed to

spouse had more than one HDHP on the

you must include the fair market value of

first of the month and one of the plans

your Archer MSA, complete Part I as

all assets in the account as of January 1,

provides family coverage, use the Family

follows.

2009, on line 6a.

coverage rules on the chart and disregard

a. Complete lines 1 and 2.

•

You used any portion of any of your

any plans with self-only coverage. If you

b. Skip lines 3 and 4.

Archer MSAs as security for a loan at any

and your spouse both have HDHPs with

c. Enter -0- on line 5.

time in 2009. You must include the fair

family coverage on the first of the month,

d. If line 2 is more than zero, see

market value of the assets used as

you both are treated as having only the

Excess Contributions You Make

security for the loan as income on Form

family coverage plan with the lowest

on page 3.

1040, line 21; or Form 1040NR, line 21.

annual deductible.

2. If you and your spouse have more

Any deemed distribution will not be

than one Archer MSA, complete Part I as

Married filing separately. If you have

treated as used to pay qualified medical

follows.

an HDHP with family coverage and are

-2-

Instructions For Form 8853 - 2009 Page 2

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