Instructions For Form 8853 - 2016 (Page 2 of 8) in pdf

How To Complete Part I

gainful activity due to a physical or mental

market value of all assets in the account as of

impairment which can be expected to result in

January 1, 2016, on line 6a.

Complete lines 1 through 5 as instructed on the

death or to continue indefinitely.

You used any portion of any of your Archer

form unless 1 or 2 next applies.

MSAs as security for a loan at any time in 2016.

Death of Account Holder

1. If employer contributions to an Archer

You must include the fair market value of the

MSA prevent you from taking a deduction for

If the account holder's surviving spouse is the

assets used as security for the loan as income

amounts you contributed to your Archer MSA,

designated beneficiary, the Archer MSA is

on Form 1040, line 21; or Form 1040NR,

complete Part I as follows.

treated as if the surviving spouse were the

line 21.

account holder. The surviving spouse

a. Complete lines 1 and 2.

Any deemed distribution won't be treated as

completes Form 8853 as though the Archer

b. Skip lines 3 and 4.

used to pay qualified medical expenses.

MSA belonged to him or her.

Generally, these distributions are subject to the

Enter -0- on line 5.

If the designated beneficiary isn't the

additional 20% tax.

d. If line 2 is more than zero, see

Excess

account holder's surviving spouse, or there is

Contributions You

Make, later.

Part I—Archer MSA

no designated beneficiary, the account ceases

2. If you and your spouse have more than

to be an Archer MSA as of the date of death.

Contributions and

one Archer MSA, complete Part I as follows.

The beneficiary completes Form 8853 as

Deductions

a. If either spouse has an HDHP with

follows.

Enter “Death of Archer MSA account holder”

family coverage, you both are treated as having

Use Part I to figure:

across the top of Form 8853.

only the family coverage plan. Disregard any

Your Archer MSA deduction,

Enter the name(s) shown on the

plans with self-only coverage.

Any excess contributions you made, and

beneficiary's tax return and the beneficiary's

b. If both spouses have HDHPs with family

Any excess contributions made by an

SSN in the spaces provided at the top of the

coverage, you both are treated as having only

employer (see

Excess Employer

Contributions,

form and skip Part I.

the family coverage plan with the lowest annual

later).

On lines 6a and 6c, enter the fair market

deductible.

Figuring Your Archer MSA

value of the Archer MSA as of the date of death.

If both spouses have HDHPs with

On line 7, for a beneficiary other than the

Deduction

self-only coverage, complete a separate Form

estate, enter qualified medical expenses

8853, Section A, Part I, for each spouse. Enter

The amount you can deduct for Archer MSA

incurred by the account holder before the date

“statement” across the top of each Form 8853,

contributions is limited by:

of death that you paid within 1 year after the

fill in the name and SSN, and complete Part I.

The applicable portion of the HDHP's annual

date of death.

Next, add lines 1, 2, and 5 from the two

deductible (line 3), and

Complete the rest of Part II.

statement Forms 8853 and enter those totals on

Your compensation from the employer

If the account holder's estate is the

the respective lines of the controlling Form

maintaining the HDHP (line 4).

beneficiary, the value of the Archer MSA as of

8853 (the combined Form 8853 for both

the date of death is included in the account

Any employer contributions made to your

spouses). Don't complete lines 3 and 4 of the

Archer MSA prevent you from making

holder's final income tax return. Complete Form

controlling Form 8853. Attach the two statement

deductible contributions. See

Employer

8853 as described above, except you should

Forms 8853 to your paper tax return after the

Contributions to an Archer

MSA, later. Also, if

complete Part I, if applicable.

controlling Form 8853.

you or your spouse made contributions in

Line 1

The distribution isn't subject to the additional

addition to any employer contributions, you may

20% tax. Report any earnings on the account

have to pay an additional tax. See

Excess

Employer Contributions

after the date of death as income on your tax

Contributions You

Make, later.

return.

Employer contributions include any amount an

You can't deduct any contributions you

employer contributes to any Archer MSA for

Note. If, during the tax year, you are the

made after you became enrolled in Medicare.

you or your spouse for 2016. These

beneficiary of two or more Archer MSAs or you

Also, you can't deduct contributions if you can

contributions should be shown in box 12 of

are a beneficiary of an Archer MSA and you

be claimed as a dependent on someone else's

Form W-2 with code R. If your employer made

have your own Archer MSA, you must complete

2016 tax return.

excess contributions, you may have to report

a separate Form 8853 for each MSA. Enter

the excess as income. See

Excess Employer

“statement” at the top of each Form 8853 and

Employer Contributions to an

Contributions, later, for details.

complete the form as instructed. Next, complete

Archer MSA

Line 2

a controlling Form 8853, combining the

amounts shown on each of the statement

If an employer made contributions to your

Include on line 2 contributions you made to your

Forms 8853. Attach the statements to your

Archer MSA, you aren't entitled to a deduction.

Archer MSA in 2016. Also include those

paper tax return after the controlling Form 8853.

If you and your spouse are covered under an

contributions made from January 1, 2017,

Deemed Distributions From

HDHP with family coverage and an employer

through April 18, 2017, that were for 2016. Don't

made contributions to either of your Archer

include amounts rolled over from another

Archer MSAs

MSAs, neither you nor your spouse are allowed

Archer MSA. See Rollovers, later.

The following situations result in deemed

to make deductible contributions to an Archer

Line 3

distributions from your Archer MSA.

MSA. If you and your spouse each have an

You engaged in any transaction prohibited

HDHP with self-only coverage and only one of

Go through the chart at the top of the

Line 3

by section 4975 with respect to any of your

you received employer contributions to an

Limitation Chart and Worksheet

for each month

Archer MSAs, at any time in 2016. Your

Archer MSA, the other spouse is allowed to

of 2016. Enter the result on the worksheet next

account ceases to be an Archer MSA as of

make deductible contributions to an Archer

January 1, 2016, and you must include the fair

MSA.

Instructions for Form 8853 (2016)

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Instructions For Form 8853 - 2016 Page 2

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