Instructions For Form 8853 - Archer Msas And Long-Term Care Insurance Contracts - 2004 Page 4
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8based on a percentage of profits, tips,
your tax return for the year you withdraw
However, if a contribution was made to an
and bonuses. Generally, these amounts
the contributions and earnings.
Archer MSA in 2004 (by you or your
are included on the Form(s) W-2 you
employer), do not include on line 9
Note. If you timely filed your return
receive from your employer(s).
withdrawals from an Archer MSA if the
without withdrawing the excess
Compensation also includes net earnings
individual for whom the expenses were
contributions, you may still make the
from self-employment, but only for a trade
incurred was not covered by an HDHP or
withdrawal no later than 6 months after
or business in which your personal
was covered by a plan that was not an
the due date of your tax return, excluding
services are a material income-producing
HDHP (other than the exceptions listed
extensions. If you do, file an amended
factor. Generally, this amount is shown on
on page 1) at the time the expenses were
return with “Filed pursuant to section
the Schedule SE (Form 1040) you
incurred.
301.9100-2” written at the top. Include an
complete for your business or farm.
Example. In 2004, you were covered
explanation of the withdrawal. Make all
Compensation does not include any
by an HDHP with self-only coverage and
necessary changes on the amended
amounts received as a pension or annuity
your spouse was covered by a health
return (for example, if you reported the
and does not include any amount
plan that was not an HDHP. You made
contributions as excess contributions on
received as deferred compensation.
contributions to an Archer MSA for 2004.
your original return, include an amended
You may not include on line 9 withdrawals
Form 5329 reflecting that the withdrawn
Line 7
made from the Archer MSA to pay your
contributions are no longer treated as
If you (or your employer) contributed
spouse’s medical expenses incurred in
having been contributed).
more to your Archer MSA than is
2004 because your spouse was covered
allowable, you may have to pay a tax on
Part III—Archer MSA
by a plan that was not an HDHP.
the excess contributions. Figure the
Distributions
excess contributions using the
You cannot take a deduction on
!
instructions below. See Form 5329,
Schedule A (Form 1040) for any
Additional Taxes on Qualified Plans
Line 8a
amount you include on line 9.
CAUTION
(Including IRAs) and Other Tax-Favored
Enter the total distributions you and your
Lines 11a and 11b
Accounts, to figure the additional tax.
spouse received in 2004 from all Archer
Excess Contributions You Make
MSAs. These amounts should be shown
Additional 15% Tax
in box 1 of Form 1099-SA.
To figure your excess contributions,
Archer MSA distributions included in
subtract your deductible contributions
Line 8b
income (line 10) are subject to an
(line 7) from your actual contributions (line
additional 15% tax unless an exception
Include on line 8b any distributions you
4). However, you may withdraw some or
applies. If any of the following exceptions
received in 2004 that were rolled over.
all of your excess contributions for 2004
apply to any of the distributions included
See Rollovers below. Also include any
and they will be treated as if they had not
on line 10, check the box on line 11a.
excess contributions (and the earnings on
been contributed if:
Enter on line 11b only 15% (.15) of any
•
those excess contributions) included on
You make the withdrawal by the due
amount included on line 10 that does not
line 8a that were withdrawn by the due
date, including extensions, of your 2004
meet any of the exceptions.
date, including extensions, of your return.
tax return,
•
See the instructions for line 7 on this
Exceptions to the Additional 15%
You do not claim a deduction for the
page.
Tax
amount of the withdrawn contributions,
and
Rollovers
The additional 15% tax does not apply to
•
You also withdraw any income earned
distributions made on or after the date
A rollover is a tax-free distribution
on the withdrawn contributions and
that the account holder —
(withdrawal) of assets from one Archer
•
include the earnings in “other income” on
Dies,
MSA that is reinvested in another Archer
•
your tax return for the year you withdraw
Becomes disabled (see page 1), or
MSA or a health savings account.
•
the contributions and earnings.
Turns age 65.
Generally, you must complete the rollover
Excess Employer Contributions
within 60 days following the distribution.
Example 1. You turned age 66 during
You may make only one rollover
the year and had no Archer MSA during
Excess employer contributions are the
the year. Your spouse turned age 63
contribution to an Archer MSA during a
excess, if any, of your employer’s
1-year period. See Pub. 590, Individual
during the year and received a distribution
contributions over the smaller of (a) your
Retirement Arrangements (IRAs), for
from an Archer MSA that is included in
limitation on line 5 or (b) your
more details and additional requirements
income. You do not check the box on line
compensation from the employer(s) who
11a because your spouse (the account
regarding rollovers.
maintained your HDHP (line 6). If the
holder) did not meet the age exception for
excess was not included in income on
Note. If you instruct the trustee of your
the distribution. You enter 15% of the
Form W-2, you must report it as “other
Archer MSA to transfer funds directly to
amount from line 10 on line 11b.
income” on your tax return. However, you
the trustee of another Archer MSA, the
may withdraw some or all of the excess
Example 2. Both you and your
transfer is not considered a rollover.
employer contributions for 2004 and they
spouse received distributions from your
There is no limit on the number of these
will be treated as if they had not been
Archer MSAs in 2004 that are included in
transfers. Do not include the amount
contributed if:
income. You were age 65 at the time you
transferred in income, deduct it as a
•
You make the withdrawal by the due
received the distributions and your
contribution, or include it as a distribution
date, including extensions, of your 2004
spouse was age 63 when he or she
on line 8a.
tax return,
received the distributions. You check the
•
Line 9
You do not claim an exclusion from
box on line 11a because the additional
income for the amount of the withdrawn
In general, include on line 9 distributions
15% tax does not apply to the
contributions, and
from all Archer MSAs in 2004 that were
distributions you received (because you
•
You also withdraw any income earned
used for the qualified medical expenses
met the age exception). However, the
on the withdrawn contributions and
(see page 1) of the account holder and
additional 15% tax does apply to your
include the earnings in “other income” on
his or her spouse or dependents.
spouse’s distributions. You enter on line
-4-
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