Instructions For Form 8853 (2015) (Page 2 of 8) in pdf

On line 7, for a beneficiary other than the

Contributions to an Archer

MSA, later. Also, if

the excess as income. See

Excess Employer

you or your spouse made contributions in

Contributions, later, for details.

estate, enter qualified medical expenses

incurred by the account holder before the date

addition to any employer contributions, you may

Line 2

have to pay an additional tax. See

Excess

of death that you paid within 1 year after the

Contributions You

Make, later.

date of death.

Include on line 2 contributions you made to your

Archer MSA in 2015. Also include those

Complete the rest of Part II.

You cannot deduct any contributions you

contributions made from January 1, 2016,

If the account holder's estate is the

made after you became enrolled in Medicare.

through April 18, 2016, that were for 2015. Do

beneficiary, the value of the Archer MSA as of

Also, you cannot deduct contributions if you can

not include amounts rolled over from another

the date of death is included in the account

be claimed as a dependent on someone else's

Archer MSA. See Rollovers, later.

holder's final income tax return. Complete Form

2015 tax return.

Line 3

8853 as described above, except you should

complete Part I, if applicable.

Go through the chart at the top of the

Line 3

Employer Contributions to an

Limitation Chart and Worksheet

for each month

The distribution is not subject to the

Archer MSA

of 2015. Enter the result on the worksheet next

additional 20% tax. Report any earnings on the

to the corresponding month. Enter the amount

account after the date of death as income on

If an employer made contributions to your

from the last line of the worksheet on line 3.

your tax return.

Archer MSA, you are not entitled to a

deduction. If you and your spouse are covered

If eligibility and coverage of both you

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

under an HDHP with family coverage and an

and your spouse did not change from

TIP

beneficiary of two or more Archer MSAs or you

employer made contributions to either of your

one month to the next, enter the same

are a beneficiary of an Archer MSA and you

Archer MSAs, neither you nor your spouse are

number you entered for the previous month. If

have your own Archer MSA, you must complete

allowed to make deductible contributions to an

eligibility and coverage did not change during

a separate Form 8853 for each MSA. Enter

Archer MSA. If you and your spouse each have

the entire year, figure the number for January

“statement” at the top of each Form 8853 and

an HDHP with self-only coverage and only one

only, and enter this amount on Form 8853,

complete the form as instructed. Next, complete

of you received employer contributions to an

line 3.

a controlling Form 8853, combining the

Archer MSA, the other spouse is allowed to

amounts shown on each of the statement

make deductible contributions to an Archer

More than one HDHP. If you and your spouse

Forms 8853. Attach the statements to your

MSA.

had more than one HDHP on the first day of the

paper tax return after the controlling Form 8853.

How To Complete Part I

month and one of the plans provides family

Deemed Distributions From

coverage, use the Family coverage rules on the

Complete lines 1 through 5 as instructed on the

chart and disregard any plans with self-only

Archer MSAs

form unless 1 or 2 next applies.

coverage. If you and your spouse both have

HDHPs with family coverage on the first day of

1. If employer contributions to an Archer

The following situations result in deemed

the month, you both are treated as having only

MSA prevent you from taking a deduction for

distributions from your Archer MSA.

the family coverage plan with the lowest annual

amounts you contributed to your Archer MSA,

You engaged in any transaction prohibited by

deductible.

complete Part I as follows.

section 4975 with respect to any of your Archer

MSAs, at any time in 2015. Your account

a. Complete lines 1 and 2.

Married filing separately. If you have an

ceases to be an Archer MSA as of January 1,

HDHP with family coverage and are married

b. Skip lines 3 and 4.

2015, and you must include the fair market

filing separately, enter only 37.5% (.375)

Enter -0- on line 5.

value of all assets in the account as of January

(one-half of 75%) of the annual deductible for

1, 2015, on line 6a.

d. If line 2 is more than zero, see

Excess

each month on the worksheet; or, if you and

You used any portion of any of your Archer

Contributions You

Make, later.

your spouse agree to divide the 75% of the

MSAs as security for a loan at any time in 2015.

annual deductible in a different manner, enter

2. If you and your spouse have more than

You must include the fair market value of the

your share.

one Archer MSA, complete Part I as follows.

assets used as security for the loan as income

Line 4

a. If either spouse has an HDHP with

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

family coverage, you both are treated as having

line 21.

Compensation

only the family coverage plan. Disregard any

Any deemed distribution will not be treated

plans with self-only coverage.

Compensation includes wages, salaries,

as used to pay qualified medical expenses.

b. If both spouses have HDHPs with family

professional fees, and other pay you receive for

Generally, these distributions are subject to the

coverage, you both are treated as having only

services you perform. It also includes sales

additional 20% tax.

the family coverage plan with the lowest annual

commissions, commissions on insurance

deductible.

premiums, pay based on a percentage of

Part I—Archer MSA

profits, tips, and bonuses. Generally, these

If both spouses have HDHPs with

Contributions and

amounts are included on the Form(s) W-2 you

self-only coverage, complete a separate Form

receive from your employer(s). Compensation

Deductions

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

also includes net earnings from

“statement” across the top of each Form 8853,

self-employment, but only for a trade or

Use Part I to figure:

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

business in which your personal services are a

Your Archer MSA deduction,

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

material income-producing factor. This is your

Any excess contributions you made, and

statement Forms 8853 and enter those totals on

income from self-employment minus expenses

the respective lines of the controlling Form

Any excess contributions made by an

(including the deductible part of

employer (see

Excess Employer

Contributions,

8853 (the combined Form 8853 for both

self-employment tax). Compensation does not

spouses). Do not complete lines 3 and 4 of the

later).

include any amounts received as a pension or

controlling Form 8853. Attach the two statement

Figuring Your Archer MSA

annuity and does not include any amount

Forms 8853 to your paper tax return after the

Deduction

received as deferred compensation.

controlling Form 8853.

Line 5

The amount you can deduct for Archer MSA

Line 1

contributions is limited by:

If you (or your employer) contributed more to

Employer Contributions

The applicable portion of the HDHP's annual

your Archer MSA than is allowable, you may

deductible (line 3), and

have to pay an additional tax on the excess

Employer contributions include any amount an

Your compensation from the employer

contributions. Figure the excess contributions

employer contributes to any Archer MSA for

maintaining the HDHP (line 4).

using the following instructions. See Form

you or your spouse for 2015. These

5329, Additional Taxes on Qualified Plans

contributions should be shown in box 12 of

Any employer contributions made to your

(Including IRAs) and Other Tax-Favored

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

Archer MSA prevent you from making

Accounts, to figure the additional tax.

excess contributions, you may have to report

deductible contributions. See

Employer

Instructions for Form 8853 (2015)

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Instructions For Form 8853 (2015) Page 2

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