MONTANA
MSA-P
Rev. 8-04
Medical Care Savings Account
Penalty Calculation
For Self-Administered Individual Accounts
15-61-201, MCA
Taxpayer Information
Name ______________________________________ Social Security Number ___________________
Account Information
Medical care savings account number ___________________________________________________
Financial institution where account is held ________________________________________________
Address of financial institution _________________________________________________________
_________________________________________________________
_________________________________________________________
If you have a medical care savings account, you must file your Montana income tax return using Form 2
(long form). All nonqualifying withdrawals from your self-administered medical care savings account
(MSA), must be included as income on line 23 of Form 2.
If you made withdrawals from a self-administered MSA that were not used to pay qualifying medical
expenses, including withdrawals made on the last business day of the tax year, you must complete the
worksheet below. Nonqualifying withdrawals, other than those made on the last business day of the tax
year, are subject to a 10% penalty.
1. Enter the total from column D of Montana Form MSA. This amount must also be
reported on line 23 of Montana Form 2 (long form). .................................................... 1. __________
2. Enter withdrawals included in column D of Form MSA were made on the last
business day in December 2004. ............................................................................... 2. __________
3. Subtract amount on line 2 from amount on line 1. ........................................................ 3. __________
4. Multiply amount on line 3 by 10% (.10). This is your penalty. Enter this amount
on line 48 of Montana Form 2 and write “MSA” in the space provided on line 48. ........ 4. __________
When you file your Montana income tax return electronically you represent that you have retained all documents
required as a tax record and that you will provide a copy to the department upon request.
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