Instructions For Form Msa - Montana Medical Care Savings Account Worksheet Page 4
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4Deposits, Withdrawals and Other Transactions
Column A
Column B
Column C
Column D
Column E
Date
Description
Deposit
Interest and
Qualified
Nonqualified
Fees and
amount
other income
withdrawals
withdrawals
other charges
Totals
Account Reconciliation
1. Beginning balance (If this is a new account, enter 0) ........................................................................ 1.
2. Total deposits (Column A)........................................................................................ 2.
3. Total interest and other income (Column B) ............................................................ 3.
4. Add lines 2 and 3 ............................................................................................................................... 4.
5. Total withdrawals (Add Columns C and D) .............................................................. 5.
6. Total fees and other charges (Column E) ................................................................ 6.
7. Add lines 5 and 6 ............................................................................................................................... 7.
8. Ending balance. Add lines 1 and 4 and subtract line 7 ..................................................................... 8.
The worksheet is provided to help you track and record the information related to your medical savings account. You are
not required to use this worksheet nor include a copy when you file your income tax return.
If your tax return is selected for review because you claimed the deduction for deposits into a medical savings account,
this worksheet can be submitted as a summary. However, you may still be asked to provide other information such as
copies of bank statements and cancelled checks.
Questions? Please call us toll free at (866) 859-2254 (in Helena, 444-6900), or access the Montana State University
Extension MontGuide at
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Parent category: Financial