Instructions For Form 8853 - 2009 (Page 4 of 8) in pdf

income” on your tax return. However, you

MSA or a health savings account.

Lines 9a and 9b

can withdraw some or all of the excess

Generally, you must complete the rollover

employer contributions for 2009 and they

Additional 15% Tax

within 60 days following the distribution.

will be treated as if they had not been

You can make only one rollover

Archer MSA distributions included in

contributed if:

contribution to an Archer MSA during a

income (line 8) are subject to an

•

You make the withdrawal by the due

1-year period. See Pub. 590, Individual

additional 15% tax unless one of the

date, including extensions, of your 2009

Retirement Arrangements (IRAs), for

following exceptions apply.

tax return (but see the Note below),

more details and additional requirements

•

Exceptions to the Additional 15%

You do not claim an exclusion from

regarding rollovers.

income for the amount of the withdrawn

Tax

contributions, and

Note. If you instruct the trustee of your

The additional 15% tax does not apply to

•

You also withdraw any income earned

Archer MSA to transfer funds directly to

distributions made after the date that the

on the withdrawn contributions and

the trustee of another Archer MSA, the

account holder —

include the earnings in “Other income” on

•

transfer is not considered a rollover.

Dies,

•

your tax return for the year you withdraw

There is no limit on the number of these

Becomes disabled (see page 1), or

•

the contributions and earnings.

transfers. Do not include the amount

Turns age 65.

transferred in income, deduct it as a

Note. If you timely filed your return

If any of the exceptions apply to any of

contribution, or include it as a distribution

without withdrawing the excess

the distributions included on line 8, check

on line 6a.

contributions, you can still make the

the box on line 9a. Enter on line 9b only

withdrawal no later than 6 months after

15% (.15) of any amount included on line

the due date of your tax return, excluding

Line 7

8 that does not meet any of the

extensions. If you do, file an amended

exceptions.

In general, include on line 7 distributions

return with “Filed pursuant to section

from all Archer MSAs in 2009 that were

Example 1. You turned age 66 in

301.9100-2” written at the top. Include an

used for the qualified medical expenses

2009 and had no Archer MSA during

explanation of the withdrawal. Make all

(see page 1) of:

2009. Your spouse turned age 63 in 2009

necessary changes on the amended

and received a distribution from an Archer

1. Yourself and your spouse.

return (for example, if you reported the

MSA that is included in income. Do not

2. All dependents you claim on your

contributions as excess contributions on

check the box on line 9a because your

tax return.

your original return, include an amended

spouse (the account holder) did not meet

Form 5329 reflecting that the withdrawn

3. Any person you could have claimed

the age exception for the distribution.

contributions are no longer treated as

as a dependent on your return except

Enter 15% of the amount from line 8 on

having been contributed).

that:

line 9b.

a. The person filed a joint return,

Deducting an Excess Contribution

Example 2. Both you and your

b. The person had gross income of

in a Later Year

spouse received distributions from your

$3,650 or more, or

Archer MSAs in 2009 that are included in

You may be able to deduct excess

c. You, or your spouse if filing jointly,

income. You were age 65 at the time you

contributions for previous years that are

could be claimed as a dependent on

received the distributions and your

still in your Archer MSA. The excess

someone else’s return.

spouse was age 63 when he or she

contribution you can deduct in the current

received the distributions. Check the box

year is the lesser of the following two

on line 9a because the additional 15% tax

amounts.

For this purpose, a child of

•

does not apply to the distributions you

Your maximum Archer MSA

TIP

parents that are divorced,

received (because you met the age

contribution limit for the year minus any

separated, or living apart for the

exception). However, the additional 15%

amounts contributed to your Archer MSA

last 6 months of the calendar year is

tax does apply to your spouse’s

for the year.

treated as the dependent of both parents

•

distributions. Enter on line 9b only 15% of

The total excess contributions in your

whether or not the custodial parent

the amount of your spouse’s distributions

Archer MSA at the beginning of the year.

releases the claim to the child’s

included in line 8.

Any excess contribution remaining at

exemption.

Example 3. You turned age 65 in

the end of a tax year is subject to the

2009. You received distributions that are

However, if a contribution was made to

additional tax. See Form 5329.

included in income both before and after

an Archer MSA in 2009 (by you or your

Part II—Archer MSA

you turned age 65. Check the box on line

employer), do not include on line 7

9a because the additional 15% tax does

withdrawals from an Archer MSA if the

Distributions

not apply to the distributions made after

individual for whom the expenses were

the date you turned age 65. However, the

incurred was not covered by an HDHP or

Line 6a

additional 15% tax does apply to the

was covered by a plan that was not an

Enter the total distributions you and your

distributions made on or before the date

HDHP (other than the exceptions listed

spouse received in 2009 from all Archer

you turned age 65. Enter on line 9b, 15%

on page 1) at the time the expenses were

MSAs. These amounts should be shown

of the amount of these distributions

incurred.

in box 1 of Form 1099-SA.

included in line 8.

Example. In 2009, you were covered

Line 6b

Section B—Medicare

by an HDHP with self-only coverage and

Include on line 6b any distributions you

your spouse was covered by a health

Advantage MSA

received in 2009 that were rolled over.

plan that was not an HDHP. You made

See Rollovers below. Also include any

Distributions

contributions to an Archer MSA for 2009.

excess contributions (and the earnings on

You cannot include on line 7 withdrawals

Complete Section B if you (or your

those excess contributions) included on

made from the Archer MSA to pay your

spouse, if filing jointly) received

line 6a that were withdrawn by the due

spouse’s medical expenses incurred in

distributions from a Medicare Advantage

date, including extensions, of your return.

2009 because your spouse was covered

MSA in 2009. If both you and your spouse

See the instructions for line 5 on page 3.

by a plan that was not an HDHP.

received distributions, complete a

Rollovers

separate Form 8853, Section B, for each

You cannot take a deduction on

A rollover is a tax-free distribution

spouse. Enter “statement” across the top

Schedule A (Form 1040) for any

(withdrawal) of assets from one Archer

of each Form 8853, fill in the name and

amount you include on line 7.

CAUTION

MSA that is reinvested in another Archer

SSN, and complete Section B. Next, add

-4-

Instructions For Form 8853 - 2009 Page 4

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