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•

Write the name(s) shown on your tax

coverage began after June 30, 1996, and

allowed to make deductible contributions

return and your SSN in the spaces

(b) the account holder has:

to an Archer MSA. If you and your spouse

•

provided at the top of the form and skip

Self-only coverage under an HDHP

each have an Archer MSA with self-only

Part II.

and did not have any health plan

coverage and only one of you received

•

On line 8a, enter the fair market value

coverage at any time during the 6-month

employer contributions to an Archer MSA,

of the Archer MSA as of the date of

period before coverage under the HDHP

the other spouse is allowed to make

death.

began.

deductible contributions to an Archer

•

On line 9, enter qualified medical

Family coverage under an HDHP and

MSA.

expenses incurred by the account holder

neither the account holder nor the

How To Complete Part II

before the date of death that you paid

account holder’s spouse had any health

within 1 year after the date of death.

plan coverage at any time during the

Complete lines 3a through 7 as instructed

•

Complete the rest of Part III.

6-month period before coverage under

on the form unless 1 or 2 below applies.

The distribution is not subject to the

the HDHP began.

1. If employer contributions to an

additional 15% tax. Report any earnings

In determining whether an account

Archer MSA prevent you from taking a

on the account after the date of death as

holder is previously uninsured, disregard

deduction for amounts you contributed to

income on your tax return.

any health insurance that is permitted in

your Archer MSA, complete Part II as

addition to the HDHP. See Other Health

follows.

Deemed Distributions From Archer

Insurance on page 1.

a. Complete lines 3a through 4.

MSAs

Lines 1c and 2c

b. Skip lines 5 and 6.

The following situations result in deemed

c. Enter -0- on line 7.

If covered by a self-only HDHP and a

distributions from your Archer MSA.

•

d. If line 4 is more than zero, see

family HDHP, indicate which plan was in

You or any of your beneficiaries

Excess Contributions You Make on

effect longer during the year.

engaged in any transaction prohibited by

page 4.

section 4975 with respect to any of your

2. If you and your spouse have more

Part II—Archer MSA

Archer MSAs, at any time in 2003. Your

than one Archer MSA, complete Part II as

account ceases to be an Archer MSA as

Contributions and

follows.

of January 1, 2003, and you must include

Deductions

a. If either spouse has an HDHP with

the fair market value of all assets in the

family coverage, you both are treated as

account as of January 1, 2003, on line 8a.

Use Part II to figure:

•

having only the family coverage plan.

•

You used any portion of any of your

Your Archer MSA deduction,

Disregard any plans with self-only

Archer MSAs as security for a loan at any

•

Any excess contributions you made,

coverage.

time in 2003. You must include the fair

and

b. If both spouses have HDHPs with

•

market value of the assets used as

Any excess contributions made by an

family coverage, you both are treated as

security for the loan as income on Form

employer (see Excess Employer

having only the family coverage plan with

1040, line 21.

Contributions on page 4).

the lowest annual deductible.

Figuring Your Archer MSA

Part I—General

c. If both spouses have HDHPs with

self-only coverage, complete a separate

Deduction

Information

Form 8853, Section A, Part II, for each

The amount you may deduct for Archer

spouse. Write “statement” across the top

Complete this part if contributions were

MSA contributions is limited by:

of each Form 8853, fill in the name and

made for 2003 by:

•

The applicable portion of the policy’s

•

SSN, and complete Part II. Next, add

You (or your employer) to your Archer

annual deductible (line 5) and

lines 3b, 4, and 7 from the two statement

•

MSA or

Your compensation from the employer

•

Forms 8853 and enter those totals on the

Your spouse (or his or her employer) to

maintaining the HDHP (line 6).

respective lines of the controlling Form

your spouse’s Archer MSA (if you are

Any employer contributions made to

8853 (the combined Form 8853 for both

filing a joint return).

your Archer MSA prevent you from

spouses). Do not complete lines 3a, 5,

making deductible contributions. See

Lines 1a and 2a

and 6 of the controlling Form 8853. Attach

Employer Contributions to an Archer

Check “Yes” on line 1a if you or your

the two statement Forms 8853 to your tax

MSA below. Also, if you or your spouse

employer made contributions to your

return after the controlling Form 8853.

made contributions in addition to any

Archer MSA for 2003, including

employer contributions, you may have to

contributions for 2003 made from January

Lines 3a and 3b

pay an additional tax. See Excess

1, 2004, through April 15, 2004.

Contributions You Make on page 4.

Otherwise, check the “No” box on line 1a.

Employer Contributions

You cannot deduct any contributions

Check “Yes” on line 2a if you are filing

Employer contributions include any

you made after you became eligible for

a joint return and your spouse (or your

amount an employer contributes to any

Medicare benefits. Also, you cannot

spouse’s employer) made contributions to

Archer MSA for you or your spouse for

deduct contributions if you can be claimed

your spouse’s Archer MSA for 2003,

2003. These contributions should be

as a dependent on someone else’s 2003

including contributions for 2003 made

shown in box 12 of Form W-2 with code

tax return.

from January 1, 2004, through April 15,

R. If your employer made excess

Employer Contributions to an

2004. Otherwise, check the “No” box on

contributions, you may have to report the

Archer MSA

line 2a.

excess as income. See Excess

Employer Contributions on page 4 for

If an employer made contributions to your

Lines 1b and 2b

details.

Archer MSA, you are not entitled to a

Check “Yes” on line 1b or 2b only if the

deduction. If you and your spouse are

Line 4

account holder is considered previously

covered under an HDHP with family

uninsured.

coverage and an employer made

Do not include amounts rolled over from

An account holder is considered

contributions to either of your Archer

another Archer MSA. See Rollovers on

previously uninsured if (a) the HDHP

MSAs, neither you nor your spouse are

page 4.

-2-

Instructions For Form 8853 - Archer Msas And Long-Term Care Insurance Contracts - 2003 Page 2

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