Instructions For Form 8853 - 2009 (Page 3 of 8) in pdf

married filing separately, enter only

Line 3 Limitation Chart and Worksheet

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

annual deductible on the worksheet; or, if

Go through this chart for each month of 2009. See the

you and your spouse agree to divide the

instructions for line 3 on page 2.

75% of the annual deductible in a

(Keep for your records)

different manner, enter your share.

Start Here

Line 4

Were you enrolled in Medicare for

Yes

the month?

Compensation

Compensation includes wages, salaries,

professional fees, and other pay you

receive for services you perform. It also

includes sales commissions,

commissions on insurance premiums, pay

Enter -0- on the line

based on a percentage of profits, tips,

Were you an eligible individual (see

and bonuses. Generally, these amounts

below for the month.

page 1 of the instructions) on the

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

first day of the month?

receive from your employer(s).

Compensation also includes net earnings

Yes

from self-employment, but only for a trade

or business in which your personal

services are a material income-producing

factor. This is your income from

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

self-employment minus expenses

month? If you had more than one HDHP, see the instructions on

(including the one-half of self-employment

page 2.

tax deduction). Generally, net earnings

and self-employment tax deduction are

shown on the Schedule SE (Form 1040)

you complete for your business or farm.

Self-only coverage

Family coverage

Compensation does not include any

Enter annual deductible

amounts received as a pension or annuity

(must be at least $2,000

(must be at least $4,000

and does not include any amount

but not more than $3,000)

but not more than $6,050)

received as deferred compensation.

Line 5

If you (or your employer) contributed

Enter 75% (.75) of the annual

Enter 65% (.65) of the annual

more to your Archer MSA than is

deductible on the line below for the

allowable, you may have to pay an

month. If married filing separately,

additional tax on the excess contributions.

month.

see instructions beginning on

Figure the excess contributions using the

page 2.

instructions below. See Form 5329,

Additional Taxes on Qualified Plans

(Including IRAs) and Other Tax-Favored

Amount from

Month in 2009

Accounts, to figure the additional tax.

chart above

Excess Contributions You Make

January

To figure your excess contributions,

subtract your deductible contributions

February

(line 5) from your actual contributions (line

March

2). However, you can withdraw some or

all of your excess contributions for 2009

April

and they will be treated as if they had not

been contributed if:

May

•

You make the withdrawal by the due

date, including extensions, of your 2009

June

tax return (but see the Note under Excess

Employer Contributions below),

July

•

You do not claim a deduction for the

amount of the withdrawn contributions,

August

and

•

September

You also withdraw any income earned

on the withdrawn contributions and

October

include the earnings in “Other income” on

your tax return for the year you withdraw

November

the contributions and earnings.

December

Excess Employer Contributions

Excess employer contributions are the

Total for all months

excess, if any, of your employer’s

contributions over the smaller of (a) your

Limitation. Divide the total by 12. Enter here and on line 3

limitation on line 3, or (b) your

compensation from the employer(s) who

maintained your HDHP (line 4). If the

excess was not included in income on

Form W-2, you must report it as “Other

-3-

Instructions For Form 8853 - 2009 Page 3

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