Instructions For Form 8853 - 2011 (Page 3 of 8) in pdf

Married filing separately. If you have

Line 3 Limitation Chart and Worksheet

an HDHP with family coverage and are

married filing separately, enter only

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

Go through this chart for each month of 2011. See the

annual deductible on the worksheet; or, if

instructions for line 3 beginning on page 2.

you and your spouse agree to divide the

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

Were you an eligible individual (see

Enter -0- on the line

based on a percentage of profits, tips,

page 1) on the rst day of the

below for the month.

and bonuses. Generally, these amounts

month?

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

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 rst day of

self-employment minus expenses

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

(including the deductible part of

page 2.

self-employment tax). Compensation

does not include any amounts received

as a pension or annuity and does not

Self-only coverage

include any amount received as deferred

Family coverage

compensation.

Enter annual deductible

(must be at least $2,050

(must be at least $4,100

Line 5

but not more than $3,050)

but not more than $6,150)

If you (or your employer) contributed

more to your Archer MSA than is

allowable, you may have to pay an

additional tax on the excess contributions.

Enter 75% (.75) of the annual

Enter 65% (.65) of the annual

Figure the excess contributions using the

deductible on the line below for the

instructions below. See Form 5329,

month. If married ling separately,

month.

Additional Taxes on Qualified Plans

see instructions on this page.

(Including IRAs) and Other Tax-Favored

Accounts, to figure the additional tax.

Excess Contributions You Make

Amount from

Month in 2011

To figure your excess contributions,

chart above

subtract your deductible contributions

(line 5) from your actual contributions (line

January

2). However, you can withdraw some or

all of your excess contributions for 2011

February

and they will be treated as if they had not

March

been contributed if:

•

You make the withdrawal by the due

April

date, including extensions, of your 2011

tax return (but see the Note under Excess

May

Employer Contributions on page 4),

•

You do not claim a deduction for the

June

amount of the withdrawn contributions,

and

July

•

You also withdraw any income earned

on the withdrawn contributions and

August

include the earnings in “Other income” on

September

your tax return for the year you withdraw

the contributions and earnings.

October

Excess Employer Contributions

November

Excess employer contributions are the

excess, if any, of your employer’s

December

contributions over the smaller of (a) your

limitation on line 3, or (b) your

Total for all months

compensation from the employer(s) who

maintained your HDHP (line 4). If the

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

excess was not included in income on

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

income” on your tax return. However, you

-3-

Instructions for Form 8853 (2011)

Instructions For Form 8853 - 2011 Page 3

Related Articles

Related forms

Related Categories