Instructions For Form 8853 - Archer Msas And Long-Term Care Insurance Contracts - 2002 Page 2
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Write the name(s) shown on your tax
An account holder is considered
allowed to make deductible contributions
return and your SSN in the spaces
previously uninsured if (a) the HDHP
to an Archer MSA. If you and your spouse
provided at the top of the form and skip
coverage began after June 30, 1996, and
each have an Archer MSA with self-only
Part II.
(b) the account holder has:
coverage and only one of you received
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On line 8a, enter the fair market value
Self-only coverage under an HDHP
employer contributions to an Archer MSA,
of the Archer MSA as of the date of
and did not have any health plan
the other spouse is allowed to make
death.
coverage at any time during the 6-month
deductible contributions to an Archer
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period before coverage under the HDHP
MSA.
On line 9, enter qualified medical
began.
expenses incurred by the account holder
How To Complete Part II
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Family coverage under an HDHP and
before the date of death that you paid
Complete lines 3a through 7 as instructed
neither the account holder nor the
within 1 year after the date of death.
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on the form unless 1 or 2 below applies.
account holder’s spouse had any health
Complete the rest of Part III.
plan coverage at any time during the
The distribution is not subject to the
1. If employer contributions to an
6-month period before coverage under
additional 15% tax. Report any earnings
Archer MSA prevent you from taking a
the HDHP began.
on the account after the date of death as
deduction for amounts you contributed to
In determining whether an account
income on your tax return.
your Archer MSA, complete Part II as
holder is previously uninsured, disregard
follows.
Deemed Distributions From
any health insurance that is permitted in
a. Complete lines 3a through 4.
Archer MSAs
addition to the HDHP. See Other Health
b. Skip lines 5 and 6.
Insurance on page 1.
The following situations result in deemed
c. Enter -0- on line 7.
distributions from your Archer MSA.
d. If line 4 is more than zero, see
Lines 1c and 2c
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Excess Contributions You Make
You or any of your beneficiaries
If covered by a self-only HDHP and a
engaged in any transaction prohibited by
beginning on page 3.
family HDHP, indicate which plan was in
section 4975 with respect to any of your
2. If you and your spouse have more
effect longer during the year.
Archer MSAs, at any time in 2002. Your
than one Archer MSA, complete Part II as
account ceases to be an Archer MSA as
follows.
Part II—Archer MSA
of January 1, 2002, and you must include
a. If either spouse has an HDHP with
the fair market value of all assets in the
Contributions and
family coverage, you both are treated as
account as of January 1, 2002, on line 8a.
having only the family coverage plan.
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Deductions
You used any portion of any of your
Disregard any plans with self-only
Archer MSAs as security for a loan at any
Use Part II to figure:
coverage.
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time in 2002. You must include the fair
Your Archer MSA deduction and, if
b. If both spouses have HDHPs with
market value of the assets used as
applicable, any excess contributions you
self-only coverage, complete a separate
security for the loan as income on Form
made and
Form 8853, Section A, Part II, for each
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1040, line 21.
Any excess contributions made by an
spouse. Write “statement” across the top
employer (see Excess Employer
of each Form 8853, fill in the name and
Part I—General
Contributions on page 4).
SSN, and complete Part II. Next, add
lines 3b, 4, and 7 from the two statement
Information
Figuring Your Archer MSA
Forms 8853 and enter those totals on the
Deduction
respective lines of the controlling Form
Complete this part if contributions were
8853 (the combined Form 8853 for both
made for 2002 by:
The amount you may deduct for Archer
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spouses). Do not complete lines 3a, 5,
You (or your employer) to your Archer
MSA contributions is limited by:
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and 6 of the controlling Form 8853. Attach
MSA or
The applicable portion of the policy’s
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the two statement Forms 8853 to your tax
Your spouse (or his or her employer) to
annual deductible (line 5) and
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return after the controlling Form 8853.
your spouse’s Archer MSA (if you are
Your compensation from the employer
filing a joint return).
maintaining the HDHP (line 6).
Lines 3a and 3b
Any employer contributions made to
Lines 1a and 2a
your Archer MSA prevent you from
Employer Contributions
making deductible contributions. See
Check “Yes” on line 1a if you or your
Employer Contributions to an Archer
employer made contributions to your
Employer contributions include any
MSA below. You may not deduct any
Archer MSA for 2002, including
amount an employer contributes to any
contributions you made after you became
contributions for 2002 made from January
Archer MSA for you or your spouse for
eligible for Medicare benefits. Also, if you
1, 2003, through April 15, 2003.
2002. These contributions should be
or your spouse made contributions in
Otherwise, check the “No” box on line 1a.
shown in box 12 of Form W-2 with code
addition to any employer contributions,
R. If your employer made excess
Check “Yes” on line 2a if you are filing
you may have to pay an additional tax.
contributions, you may have to report the
a joint return and your spouse (or your
See Excess Contributions You Make
excess as income. See Excess
spouse’s employer) made contributions to
beginning on page 3.
Employer Contributions on page 4 for
your spouse’s Archer MSA for 2002,
details.
Employer Contributions to an
including contributions for 2002 made
Archer MSA
Line 4
from January 1, 2003, through April 15,
2003. Otherwise, check the “No” box on
If an employer made contributions to your
Do not include amounts rolled over from
line 2a.
Archer MSA, you are not entitled to a
another Archer MSA. See Rollovers on
deduction. If you and your spouse are
page 4.
Lines 1b and 2b
covered under an HDHP with family
Line 5
Check “Yes” on line 1b or 2b only if the
coverage and an employer made
account holder is considered previously
contributions to either of your Archer
Go through the chart at the top of the
uninsured.
MSAs, neither you nor your spouse are
Line 5 Limitation Chart and Worksheet
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