Form 8853 - Medical Savings Accounts And Long-Term Care Insurance Contracts - 1998
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1
28853
Medical Savings Accounts
OMB No. 1545-1561
1998
Form
and Long-Term Care Insurance Contracts
Attachment
Department of the Treasury
39
Attach to Form 1040.
See separate instructions.
Sequence No.
Internal Revenue Service
Social security number of MSA
Name(s) shown on return
account holder. If both spouses
have MSAs, see instructions
Section A. Medical Savings Accounts (MSAs)
Part I
General Information—You MUST complete this part if you (or your spouse, if married filing jointly)
established a new MSA for 1998 (even if the contributions to the MSA were made by an employer).
Yes No
1a
1a
Did you establish a new MSA for 1998?
1b
b
If “Yes,” were you a previously uninsured account holder (see instructions for definition)?
c
If line 1a is “Yes,” indicate coverage under high deductible health plan:
Self-Only
OR
Family
2a
2a
If you were married, did your spouse establish a new MSA for 1998?
2b
b
If “Yes,” was your spouse a previously uninsured account holder (see instructions for definition)?
c
If line 2a is “Yes,” indicate coverage under high deductible health plan:
Self-Only
OR
Family
Part II
MSA Contributions and Deductions—See instructions before completing this part.
If you and your spouse each have high deductible health plans with self-only coverage, check here
If you check this box, attach a separate Part II for each spouse (see instructions).
3a
Were any employer contributions made to your MSA(s)?
Yes
No
b
Enter all employer contributions to your MSA(s) for 1998
4
Enter MSA contributions that you made for 1998, including those made from 1/1/99 through 4/15/99
4
that were for 1998. Do not include amounts rolled over from another MSA (see instructions)
5
5
Enter your limitation from the worksheet on page 3 of the instructions
6
Enter your compensation (see instructions) from the employer maintaining the high deductible
health plan. If you (and your spouse, if married filing jointly) have more than one plan, see How
To Complete Part II on page 2 of the instructions. (If self-employed, enter your earned income
6
from the trade or business for which the high deductible health plan was established.)
7
7
MSA deduction. Enter the smallest of lines 4, 5, and 6 here and on Form 1040, line 25
Note: If line 4 is more than line 7, you may have to pay an additional tax. See instructions for
details.
Part III
MSA Distributions
8a Enter the total MSA distributions you and your spouse received from all MSAs during 1998 (see
8a
instructions)
b
Enter any distributions included on line 8a that you rolled over to another MSA (see instructions).
Also enter any excess contributions (and the earnings on those excess contributions) included
8b
on line 8a that were withdrawn by the due date of your return
8c
c
Subtract line 8b from line 8a
9
9
Enter your total unreimbursed qualified medical expenses (see instructions)
10
Taxable MSA distributions. Subtract line 9 from line 8c. If zero or less, enter -0-. Enter the
result here. If line 10 is more than zero, also include it in the total on Form 1040, line 21. On the
10
dotted line next to line 21, enter “MSA” and show the amount
11a
If you meet any of the Exceptions to 15% Tax (see instructions), check here
b
Otherwise, multiply line 10 by 15% (.15). Enter the result here and
include it in the total on Form 1040, line 56. On the dotted line next
to line 56, enter “MSA” and the amount
11b
8853
For Paperwork Reduction Act Notice, see page 8 of the instructions.
Cat. No. 24091H
Form
(1998)
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