Form In-Msa - Indiana Individual Medical Savings Accounts (Page 2 of 2) in pdf

Instructions for Plan Administrator (Payer) and Employee

The plan administrator must report medical savings account information for each employee with respect to contributions, rollovers, interest income

earned during the taxable year, distributions made to the account holder and amounts subject to penalty.

From activity during the tax year: Enter total contributions in Box 1; Enter total withdrawals for medical reimbursements in Box 2; Enter rollovers in

Box 3; Enter the nonmedical withdrawals made that are not subject to penalty in Box 4; Enter taxable interest from the account (that is also reported on

Form 1099 INT) in Box 5; Enter the nonmedical withdrawals that are subject to penalty under IC 6-8-11-17(c) in Box 6; Enter in Box 7 the amount of

interest (also included in the Box 5 total) that is exempt from Indiana adjusted gross income tax (that portion earned from employee's contribution).

If there is a Box 6 entry the plan administrator must, by January 1 following the end of the tax year, mail:

a copy of this form;

Form MSA-3; and

the penalty amount withheld to:

Indiana Department of Revenue

P.O. Box 935

Indianapolis, IN 46206-0935

The employee must attach this form to the Indiana individual income tax return only when claiming an Indiana medical savings account deduction.

Instructions for Plan Administrator (Payer) and Employee

The plan administrator must report medical savings account information for each employee with respect to contributions, rollovers, interest income

earned during the taxable year, distributions made to the account holder and amounts subject to penalty.

From activity during the tax year: Enter total contributions in Box 1; Enter total withdrawals for medical reimbursements in Box 2; Enter rollovers in

Box 3; Enter the nonmedical withdrawals made that are not subject to penalty in Box 4; Enter taxable interest from the account (that is also reported on

Form 1099 INT) in Box 5; Enter the nonmedical withdrawals that are subject to penalty under IC 6-8-11-17(c) in Box 6; Enter in Box 7 the amount of

interest (also included in the Box 5 total) that is exempt from Indiana adjusted gross income tax (that portion earned from employee's contribution).

If there is a Box 6 entry the plan administrator must, by January 1 following the end of the tax year, mail:

a copy of this form;

Form MSA-3; and

the penalty amount withheld to:

Indiana Department of Revenue

P.O. Box 935

Indianapolis, IN 46206-0935

The employee must attach this form to the Indiana individual income tax return only when claiming an Indiana medical savings account deduction.

Instructions for Plan Administrator (Payer) and Employee

The plan administrator must report medical savings account information for each employee with respect to contributions, rollovers, interest income

earned during the taxable year, distributions made to the account holder and amounts subject to penalty.

From activity during the tax year: Enter total contributions in Box 1; Enter total withdrawals for medical reimbursements in Box 2; Enter rollovers in

Box 3; Enter the nonmedical withdrawals made that are not subject to penalty in Box 4; Enter taxable interest from the account (that is also reported on

Form 1099 INT) in Box 5; Enter the nonmedical withdrawals that are subject to penalty under IC 6-8-11-17(c) in Box 6; Enter in Box 7 the amount of

interest (also included in the Box 5 total) that is exempt from Indiana adjusted gross income tax (that portion earned from employee's contribution).

If there is a Box 6 entry the plan administrator must, by January 1 following the end of the tax year, mail:

a copy of this form;

Form MSA-3; and

the penalty amount withheld to:

Indiana Department of Revenue

P.O. Box 935

Indianapolis, IN 46206-0935

The employee must attach this form to the Indiana individual income tax return only when claiming an Indiana medical savings account deduction.