Form In-Msa - Indiana Individual Medical Savings Accounts
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1
2PAYER'S name, street address, city state and zip code
Indiana Individual
CORRECTED
20___
(if checked)
Medical Savings
1. Contributions
Accounts
Year
2. Medical withdrawals
MSA
PAYER'S Federal identification number
RECIPIENT'S social security number
Attach to state tax
3. Rollovers
return if required
Attach this form to your
RECIPIENT'S name, street address (including apt. no.), city, state and zip code 4. Nonmedical withdrawals
6. Nonmedical withdrawals
Indiana income tax re-
not subject to penalty
subject to penalty
turn if you are claiming
Box 2 &/or Box 7 as a
deduction on your Indi-
5. Interest - taxable
7. Interest - exempt
ana income tax return.
IN-MSA
Form
SF 48244, Rev. 8/00
Indiana Department of Revenue
PAYER'S name, street address, city state and zip code
Indiana Individual
CORRECTED
20___
(if checked)
Medical Savings
1. Contributions
Accounts
Year
2. Medical withdrawals
MSA
PAYER'S Federal identification number
RECIPIENT'S social security number
Attach to state tax
3. Rollovers
return if required
Attach this form to your
RECIPIENT'S name, street address (including apt. no.), city, state and zip code 4. Nonmedical withdrawals
6. Nonmedical withdrawals
Indiana income tax re-
not subject to penalty
subject to penalty
turn if you are claiming
Box 2 &/or Box 7 as a
deduction on your Indi-
5. Interest - taxable
7. Interest - exempt
ana income tax return.
IN-MSA
Form
SF 48244, Rev. 8/00
Indiana Department of Revenue
PAYER'S name, street address, city state and zip code
Indiana Individual
CORRECTED
20___
(if checked)
Medical Savings
1. Contributions
Accounts
Year
2. Medical withdrawals
MSA
PAYER'S Federal identification number
RECIPIENT'S social security number
Attach to state tax
3. Rollovers
return if required
Attach this form to your
RECIPIENT'S name, street address (including apt. no.), city, state and zip code 4. Nonmedical withdrawals
6. Nonmedical withdrawals
Indiana income tax re-
not subject to penalty
subject to penalty
turn if you are claiming
Box 2 &/or Box 7 as a
deduction on your Indi-
5. Interest - taxable
7. Interest - exempt
ana income tax return.
IN-MSA
Form
SF 48244, Rev. 8/00
Indiana Department of Revenue
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