Montana Form Msa - Montana Medical Care Savings Account - 2012
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MONTANA
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MSA
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Rev 02 12
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2012 Montana Medical Care Savings Account
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Annual Reporting Information for Self-Administered Accounts
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15-61-101 through 15-61-205, MCA
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Social Security Number
First Name and Initial
Last Name
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-
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Name and address of the fi nancial institution where your Montana medical care savings account is established:
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__________________________________________________________________________________________
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__________________________________________________________________________________________
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__________________________________________________________________________________________
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Your Montana medical care savings account number:
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Part I. Allowable Deduction Calculation
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1. Current year deposits (Column A if using MSA-Worksheet) ....................... 1.
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2. Deposits from prior years not previously deducted .................................... 2.
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3. Add lines 1 and 2 ........................................................................................ 3.
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4. Enter the lesser of the amount on line 3 or $3,000...................................................................4.
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5. Interest and other income (Column B if using MSA-Worksheet) ..............................................5.
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6. Add lines 4 and 5. This is your Montana Medical Saving Account exclusion. Enter this
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amount on Form 2, Schedule II, line 18 or Form 2M, line 32 ...................................................6.
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7. If the amount on line 3 is greater than $3,000, subtract line 4 from line 3.
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These are your excess deposits that may be excluded next year ............................................7.
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Part II. Nonqualifi ed Withdrawals
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1. Nonqualifi ed withdrawals (Column D if using MSA-Worksheet) ...............................................1.
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Enter this amount on Form 2, Schedule I, line 7 or Form 2M, line 25.
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2. Enter the withdrawals on line 1 made on the last business day in December 2012 ................2.
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3. Subtract line 2 from line 1 .........................................................................................................3.
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4. Multiply the amount on line 3 by 10% (0.10). Enter this amount on Form 2, line 68 or
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Form 2M, line 59, and write “MSA” in the space provided. This is your penalty .......................4.
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The Montana Medical Care Savings Account Worksheet (MSA-Worksheet) is available to help you reconcile the activity
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on this form by providing a log to track expenses, deposits, withdrawals, fees and other transactions. It is not required to
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be completed or included with your tax return. (The MSA-Worksheet follows the instructions for this form.)
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If you fi le your Montana tax return electronically, you do not need to mail this form to us unless we ask you for a copy. When you fi le electronically, you
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represent that you have retained the required documents in your tax records and will provide them upon the department’s request.
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*12DL0101*
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*12DL0101*
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