Instructions For Form 8853 - Archer Msas And Long-Term Care Insurance Contracts - 2004 Page 2
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8spouse completes Form 8853 as though
Lines 1a and 2a
Any employer contributions made to
the Archer MSA belonged to him or her.
your Archer MSA prevent you from
Check “Yes” on line 1a if you or your
making deductible contributions. See
If the designated beneficiary is not the
employer made contributions to your
Employer Contributions to an Archer MSA
account holder’s surviving spouse, or
Archer MSA for 2004, including
below. Also, if you or your spouse made
there is no designated beneficiary, the
contributions for 2004 made from January
contributions in addition to any employer
account ceases to be an Archer MSA as
1, 2005, through April 15, 2005.
contributions, you may have to pay an
of the date of death. The beneficiary
Otherwise, check the “No” box on line 1a.
additional tax. See Excess Contributions
completes Form 8853 as follows.
Check “Yes” on line 2a if you are filing
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You Make on page 4.
Write “Death of Archer MSA account
a joint return and your spouse (or your
holder” across the top of Form 8853.
You cannot deduct any contributions
spouse’s employer) made contributions to
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Write the name(s) shown on your tax
you made after you became enrolled in
your spouse’s Archer MSA for 2004,
return and your SSN in the spaces
Medicare. Also, you cannot deduct
including contributions for 2004 made
provided at the top of the form and skip
contributions if you can be claimed as a
from January 1, 2005, through April 15,
Part II.
dependent on someone else’s 2004 tax
2005. Otherwise, check the “No” box on
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On line 8a, enter the fair market value
return.
line 2a.
of the Archer MSA as of the date of
Employer Contributions to an
death.
Lines 1b and 2b
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Archer MSA
On line 9, for a beneficiary other than
Check “Yes” on line 1b or 2b only if the
the estate, enter qualified medical
If an employer made contributions to your
account holder is considered previously
expenses incurred by the account holder
Archer MSA, you are not entitled to a
uninsured.
before the date of death that you paid
deduction. If you and your spouse are
within 1 year after the date of death.
An account holder is considered
covered under an HDHP with family
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previously uninsured if the HDHP
Complete the rest of Part III.
coverage and an employer made
coverage began after June 30, 1996, and
contributions to either of your Archer
If the account holder’s estate is the
the account holder has:
MSAs, neither you nor your spouse are
beneficiary, the value of the Archer MSA
1. Self-only coverage under an HDHP
allowed to make deductible contributions
as of the date of death is included in the
and did not have any health plan
to an Archer MSA. If you and your spouse
account holder’s final income tax return.
coverage at any time during the 6-month
each have an Archer MSA with self-only
Complete Form 8853 as described above,
period before coverage under the HDHP
coverage and only one of you received
except you should complete Part II, if
began, or
employer contributions to an Archer MSA,
applicable.
2. Family coverage under an HDHP
the other spouse is allowed to make
The distribution is not subject to the
and neither the account holder nor the
deductible contributions to an Archer
additional 15% tax. Report any earnings
account holder’s spouse had any health
MSA.
on the account after the date of death as
plan coverage at any time during the
income on your tax return.
How To Complete Part II
6-month period before coverage under
Deemed Distributions From Archer
the HDHP began.
Complete lines 3 through 7 as instructed
on the form unless 1 or 2 below applies.
MSAs
In determining whether an account
1. If employer contributions to an
The following situations result in deemed
holder is previously uninsured, disregard
Archer MSA prevent you from taking a
distributions from your Archer MSA.
any health insurance that is permitted in
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deduction for amounts you contributed to
You engaged in any transaction
addition to the HDHP. See Other Health
your Archer MSA, complete Part II as
prohibited by section 4975 with respect to
Coverage on page 1.
follows.
any of your Archer MSAs, at any time in
2004. Your account ceases to be an
a. Complete lines 3 and 4.
Lines 1c and 2c
Archer MSA as of January 1, 2004, and
b. Skip lines 5 and 6.
If covered by a self-only HDHP and a
you must include the fair market value of
c. Enter -0- on line 7.
family HDHP, indicate which plan was in
all assets in the account as of January 1,
d. If line 4 is more than zero, see
effect longer during the year.
2004, on line 8a.
Excess Contributions You Make
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You used any portion of any of your
on page 4.
Part II—Archer MSA
Archer MSAs as security for a loan at any
2. If you and your spouse have more
time in 2004. You must include the fair
Contributions and
than one Archer MSA, complete Part II as
market value of the assets used as
follows.
Deductions
security for the loan as income on Form
a. If either spouse has an HDHP with
1040, line 21.
Use Part II to figure:
family coverage, you both are treated as
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Your Archer MSA deduction,
having only the family coverage plan.
Any deemed distribution will not be
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Any excess contributions you made,
Disregard any plans with self-only
treated as used to pay qualified medical
and
coverage.
expenses. Generally, these distributions
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Any excess contributions made by an
b. If both spouses have HDHPs with
will be subject to the additional 15% tax.
employer (see Excess Employer
family coverage, you both are treated as
Contributions on page 4).
Part I—General
having only the family coverage plan with
the lowest annual deductible.
Information
Figuring Your Archer MSA
c. If both spouses have HDHPs with
Deduction
Complete this part if contributions were
self-only coverage, complete a separate
made for 2004 by:
The amount you may deduct for Archer
Form 8853, Section A, Part II, for each
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You (or your employer) to your Archer
MSA contributions is limited by:
spouse. Write “statement” across the top
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MSA, or
The applicable portion of the HDHP’s
of each Form 8853, fill in the name and
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Your spouse (or his or her employer) to
annual deductible (line 5) and
SSN, and complete Part II. Next, add
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your spouse’s Archer MSA (if you are
Your compensation from the employer
lines 3, 4, and 7 from the two statement
filing a joint return).
maintaining the HDHP (line 6).
Forms 8853 and enter those totals on the
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