Instructions For Form 8853 - 2016 Page 3
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8Line 3 Limitation Chart and Worksheet
to the corresponding month. Enter the amount
from the last line of the worksheet on line 3.
Go through this chart for each month of 2016.
If eligibility and coverage of both you
See the instructions for line 3.
and your spouse didn't change from
TIP
(Keep for your records)
one month to the next, enter the
Start Here
same number you entered for the previous
Were you enrolled in Medicare for
month. If eligibility and coverage didn't change
Yes
the month?
during the entire year, figure the number for
January only, and enter this amount on Form
8853, line 3.
No
More than one HDHP. If you and your spouse
had more than one HDHP on the first day of the
Were you an eligible individual (see
Enter -0- on the line
month and one of the plans provides family
No
Eligible Individual, earlier) on the rst
below for the month.
coverage, use the Family coverage rules on the
day of the month?
chart and disregard any plans with self-only
coverage. If you and your spouse both have
HDHPs with family coverage on the first day of
Yes
the month, you both are treated as having only
the family coverage plan with the lowest annual
deductible.
What type of coverage did your HDHP provide on the rst day of
the month? If you had more than one HDHP, see More than one
Married filing separately. If you have an
HDHP, earlier.
HDHP with family coverage and are married
filing separately, enter only 37.5% (0.375)
(one-half of 75%) of the annual deductible for
Self-only coverage
Family coverage
each month on the worksheet; or, if you and
Enter annual deductible
Enter annual deductible
your spouse agree to divide the 75% of the
(must be at least $2,250
(must be at least $4,450
annual deductible in a different manner, enter
but not more than $3,350)
but not more than $6,700)
your share.
$
$
Line 4
Compensation
Enter 75% (0.75) of the annual
Enter 65% (0.65) of the annual
deductible on the line below for the
deductible on the line below for the
Compensation includes wages, salaries,
month. If married ling separately,
month.
professional fees, and other pay you receive for
see Married filing separately.
services you perform. It also includes sales
commissions, commissions on insurance
premiums, pay based on a percentage of
Amount from
Month in 2016
profits, tips, and bonuses. Generally, these
chart above
amounts are included on the Form(s) W-2 you
January
receive from your employer(s). Compensation
also includes net earnings from
February
self-employment, but only for a trade or
March
business in which your personal services are a
material income-producing factor. This is your
April
income from self-employment minus expenses
(including the deductible part of
May
self-employment tax). Compensation doesn't
June
include any amounts received as a pension or
annuity and doesn't include any amount
July
received as deferred compensation.
August
Line 5
September
If you (or your employer) contributed more to
October
your Archer MSA than is allowable, you may
have to pay an additional tax on the excess
November
contributions. Figure the excess contributions
using the following instructions. See Form
December
5329, Additional Taxes on Qualified Plans
Total for all months
(Including IRAs) and Other Tax-Favored
Accounts, to figure the additional tax.
Limitation. Divide the total by 12. Enter here and on line 3
Instructions for Form 8853 (2016)
-3-
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