Instructions For Form 8853 (2015) Page 3
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8Line 3 Limitation Chart and Worksheet
Excess Contributions You Make
To figure your excess contributions, subtract
Go through this chart for each month of 2015.
your deductible contributions (line 5) from your
See the instructions for line 3.
actual contributions (line 2). However, you can
(Keep for your records)
withdraw some or all of your excess
Start Here
contributions for 2015 and they will be treated
as if they had not been contributed if:
Were you enrolled in Medicare for
You make the withdrawal by the due date,
Yes
the month?
including extensions, of your 2015 tax return
(but see the
Note
under Excess Employer
Contributions),
You do not claim a deduction for the amount
No
of the withdrawn contributions, and
You also withdraw any income earned on the
withdrawn contributions and include the
Were you an eligible individual (see
Enter -0- on the line
earnings in “Other income” on your tax return
No
Eligible Individual, earlier) on the rst
below for the month.
for the year you withdraw the contributions and
day of the month?
earnings.
Excess Employer Contributions
Yes
Excess employer contributions are the excess,
if any, of your employer's contributions over the
smaller of (a) your limitation on line 3, or (b)
What type of coverage did your HDHP provide on the rst day of
your compensation from the employer(s) who
the month? If you had more than one HDHP, see More than one
maintained your HDHP (line 4). If the excess
HDHP, earlier.
was not included in income on Form W-2, you
must report it as “Other income” on your tax
return. However, you can withdraw some or all
of the excess employer contributions for 2015
Self-only coverage
Family coverage
and they will be treated as if they had not been
Enter annual deductible
Enter annual deductible
contributed if:
(must be at least $2,200
(must be at least $4,450
You make the withdrawal by the due date,
but not more than $3,300)
but not more than $6,650)
including extensions, of your 2015 tax return
$
$
(but see the
Note
later),
You do not claim an exclusion from income
for the amount of the withdrawn contributions,
Enter 75% (.75) of the annual
and
Enter 65% (.65) of the annual
You also withdraw any income earned on the
deductible on the line below for the
deductible on the line below for the
withdrawn contributions and include the
month. If married ling separately,
month.
earnings in “Other income” on your tax return
see Married filing separately.
for the year you withdraw the contributions and
earnings.
Amount from
Note. If you timely filed your return without
Month in 2015
chart above
withdrawing the excess contributions, you can
still make the withdrawal no later than 6 months
January
after the due date of your tax return, excluding
extensions. If you do, file an amended return
February
with “Filed pursuant to section 301.9100-2”
written at the top. Include an explanation of the
March
withdrawal. Make all necessary changes on the
amended return (for example, if you reported
April
the contributions as excess contributions on
your original return, include an amended Form
May
5329 reflecting that the withdrawn contributions
are no longer treated as having been
June
contributed).
July
Deducting an Excess Contribution
August
in a Later Year
September
You may be able to deduct excess
contributions for previous years that are still in
October
your Archer MSA. The excess contribution you
can deduct in the current year is the lesser of
November
the following two amounts.
Your maximum Archer MSA contribution limit
December
for the year minus any amounts contributed to
your Archer MSA for the year.
Total for all months
The total excess contributions in your Archer
Limitation. Divide the total by 12. Enter here and on line 3
MSA at the beginning of the year.
Any excess contribution remaining at the
end of a tax year is subject to the additional tax.
See Form 5329.
Instructions for Form 8853 (2015)
-3-
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