4835 Farm Rental Income and Expenses

U.S. Individual Income Tax Return

4835

U.S. Individual Income Tax Return

OMB: 1545-0074

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8853

Department of the Treasury
Internal Revenue Service (99)

Action

Date

O.K. to print
Revised proofs
requested

OMB No. 1545-0074

Archer MSAs and
Long-Term Care Insurance Contracts
©

2006

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Attach to Form 1040 or Form 1040NR.

Name(s) shown on Form 1040

Signature

Attachment
Sequence No.

See separate instructions.

Social security number of MSA
account holder. If both spouses
have MSAs, see page 1 of the instructions

Section A. Archer MSAs. If you have only a Medicare Advantage MSA, skip Section A and complete Section B.
General Information. See page 2 of the instructions.
Part I
1a
b
c
2a
b
c

Did you or your employer make contributions to your Archer MSA for 2006?
If “Yes,” were you uninsured when the MSA was established (see page 2 of the instructions)?
If line 1a is “Yes,” indicate coverage under high deductible health plan:
Self-Only
or
Family
If married, did your spouse or spouse’s employer make contributions to your spouse’s Archer MSA for 2006?
If “Yes,” was your spouse uninsured when the MSA was established (see page 2 of the instructions)?
If line 2a is “Yes,” indicate coverage under high deductible health plan:
Self-Only
or
Family

Part II

3
4
5
6

Yes No

1a
1b
2a
2b

Archer MSA Contributions and Deductions. See page 2 of the instructions before completing this part.
If you are filing jointly and both you and your spouse have high deductible health plans with self-only
coverage, complete a separate Part II for each spouse (see page 2 of the instructions).

3
Total employer contributions to your Archer MSA(s) for 2006
Archer MSA contributions you made for 2006, including those made from January 1, 2007, through
April 16, 2007, that were for 2006. Do not include rollovers (see page 4 of the instructions)
Limitation from the worksheet on page 3 of the instructions

4
5

Compensation (see page 3 of the instructions) from the employer maintaining the high deductible
health plan. (If self-employed, enter your earned income from the trade or business under which
6
the high deductible health plan was established.)
Archer MSA deduction. Enter the smallest of line 4, 5, or 6 here and on Form 1040, line 23, or
7
Form 1040NR, line 23
Caution: If line 4 is more than line 7, you may have to pay an additional tax (see page 4 of the instructions).

Part III

Archer MSA Distributions

8a Total distributions you and your spouse received in 2006 from all Archer MSAs (see page 4 of
the instructions)

b Distributions included on line 8a that you rolled over to another Archer MSA or a health savings account.
Also include any excess contributions (and the earnings on those excess contributions) included on
line 8a that were withdrawn by the due date of your return (see page 4 of the instructions)
c Subtract line 8b from line 8a
9 Unreimbursed qualified medical expenses (see page 4 of the instructions)

8b
8c
9

Taxable Archer MSA distributions. Subtract line 9 from line 8c. If zero or less, enter -0-. Also
include this amount in the total on Form 1040, line 21, or Form 1040NR, line 21. On the dotted
line next to line 21, enter “MSA” and the amount
11a If any of the distributions included on line 10 meet any of the Exceptions to the Additional
©
15% Tax (see page 4 of the instructions), check here
b Additional 15% tax (see page 4 of the instructions). Enter 15% (.15) of the distributions included
on line 10 that are subject to the additional 15% tax. Also include this amount in the total on
Form 1040, line 63, or Form 1040NR, line 58. On the dotted line next to Form 1040, line 63, or
Form 1040NR, line 58, enter “MSA” and the amount

Section B.

12
13

11b

Medicare Advantage MSA Distributions. If you are filing jointly and both you and your spouse received
distributions in 2006 from a Medicare Advantage MSA, complete a separate Section B for each spouse
(see page 5 of the instructions).

Total distributions you received in 2006 from all Medicare Advantage MSAs (see page 5 of the
instructions)
Unreimbursed qualified medical expenses (see page 5 of the instructions)

Taxable Medicare Advantage MSA distributions. Subtract line 13 from line 12. If zero or less,
enter -0-. Also include this amount in the total on Form 1040, line 21, or Form 1040NR, line 21.
On the dotted line next to line 21, enter “Med MSA” and the amount
15a If any of the distributions included on line 14 meet any of the Exceptions to the Additional
©
50% Tax (see page 5 of the instructions), check here
b Additional 50% tax (see page 5 of the instructions). Also include this amount in the total on
Form 1040, line 63, or Form 1040NR, line 58. On the dotted line next to Form 1040, line 63, or
Form 1040NR, line 58, enter “Med MSA” and the amount

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For Paperwork Reduction Act Notice, see page 8 of the instructions.

Cat. No. 24091H

15b
Form

8853

(2006)

3
I.R.S. SPECIFICATIONS
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INSTRUCTIONS TO PRINTERS
FORM 8853, PAGE 2 of 2
MARGINS: TOP 13mm (1⁄ 2 "), CENTER SIDES. PRINTS: HEAD to HEAD
PAPER: WHITE, WRITING, SUB. 20
INK: BLACK
FLAT SIZE: 216mm (81⁄ 2 ") 3 279mm (11")
PERFORATE: (NONE)
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Form 8853 (2006)

Attachment Sequence No.

Name of policyholder (as shown on Form 1040)

Page

Social security number
of policyholder ©

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Section C. Long-Term Care (LTC) Insurance Contracts. See Filing Requirements for Section C on page 6 of
the instructions before completing this section.
©

If more than one Section C is attached, check here
16a Name of insured
17

b Social security number of insured

In 2006, did anyone other than you receive payments on a per diem or other periodic basis under a qualified
LTC insurance contract covering the insured or receive accelerated death benefits under a life insurance
policy covering the insured?

Was the insured a terminally ill individual?
Note: If “Yes” and the only payments you received in 2006 were accelerated death benefits that were paid
to you because the insured was terminally ill, skip lines 19 through 27 and enter -0- on line 28.

Gross LTC payments received on a per diem or other periodic basis. Enter the total of the amounts
from box 1 of all Forms 1099-LTC you received with respect to the insured on which the “Per
diem” box in box 3 is checked

Yes

Caution: Do not use lines 20 through 28 to figure the taxable amount of benefits paid under an
LTC insurance contract that is not a qualified LTC insurance contract. Instead, if the benefits
are not excludable from your income (for example, if the benefits are not paid for personal injuries
or sickness through accident or health insurance), report the amount not excludable as income
on Form 1040, line 21.
20

Enter the part of the amount on line 19 that is from qualified LTC insurance contracts

Accelerated death benefits received on a per diem or other periodic basis. Do not include any
amounts you received because the insured was terminally ill (see page 7 of the instructions)

Add lines 20 and 21

Note: If you checked “Yes” on line 17 above, see Multiple Payees
on page 7 of the instructions before completing lines 23 through 27.
23
24

25
26

Multiply $250 by the number of days in the LTC period
Costs incurred for qualified LTC services provided for the insured
during the LTC period (see page 7 of the instructions)

Enter the larger of line 23 or line 24
Reimbursements for qualified LTC services provided for the insured
during the LTC period

Caution: If you received any reimbursements from LTC contracts
issued before August 1, 1996, see page 7 of the instructions.
27

Per diem limitation. Subtract line 26 from line 25

Taxable payments. Subtract line 27 from line 22. If zero or less, enter -0-. Also include this
amount in the total on Form 1040, line 21. On the dotted line next to line 21, enter “LTC” and
the amount

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8853

(2006)

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Page 1 of 8

Instructions for Form 8853

14:31 - 13-DEC-2005

The type and rule above prints on all proofs including departmental reproduction proofs. MUST be removed before printing.

2005

Department of the Treasury
Internal Revenue Service

Instructions for Form 8853
Archer MSAs and Long-Term Care Insurance Contracts

General Instructions
Section references are to the Internal
Revenue Code unless otherwise noted.

Advantage MSA, enter the SSN shown
first on your tax return.

• Report Archer MSA contributions
(including employer contributions),
• Figure your Archer MSA deduction,
• Report distributions from Archer MSAs
or Medicare Advantage MSAs,
• Report taxable payments from
long-term care (LTC) insurance contracts,
or
• Report taxable accelerated death
benefits from a life insurance policy.
Additional information. See Pub. 969,
Health Savings Accounts and Other
Tax-Favored Health Plans, for more
details on MSAs.

Minimum annual
deductible

$1,750

$3,500

Eligible Individual

Maximum annual
deductible

$2,650

$5,250

Maximum annual
out-of-pocket expenses
(other than for premiums)

$3,500

$6,450

To be eligible for an Archer MSA, you (or
your spouse) must be an employee of a
small employer or be self-employed. You
(or your spouse) must be covered under a
high deductible health plan (HDHP) and
have no other health coverage except
permitted coverage. You must not be
enrolled in Medicare and cannot be
claimed as a dependent on someone
else’s 2005 tax return. You must be an
eligible individual on the first day of a
month to take an Archer MSA deduction
for that month.

Small Employer

Who Must File
You must file Form 8853 if any of the
following applies.
• You (or your employer) made
contributions for 2005 to your Archer
MSA.
• You are filing a joint return and your
spouse (or his or her employer) made
contributions for 2005 to your spouse’s
Archer MSA.
• You (or your spouse, if filing jointly)
received Archer MSA or Medicare
Advantage MSA distributions in 2005.
• You acquired an interest in an Archer
MSA or a Medicare Advantage MSA
because of the death of the account
holder. See Death of Account Holder that
begins on this page.
• You (or your spouse, if filing jointly)
were a policyholder who received
payments under an LTC insurance
contract or received any accelerated
death benefits from a life insurance policy
on a per diem or other periodic basis in
2005. See the instructions for Section C,
that begin on page 6.

Specific Instructions
Name and social security number
(SSN). Enter your name(s) and SSN as
shown on your tax return. If filing jointly
and both you and your spouse each have
an Archer MSA or each have a Medicare

Family
coverage

Section A—Archer MSAs

Purpose of Form
Use Form 8853 to:

Self-only
coverage

A small employer is generally an
employer who had an average of 50 or
fewer employees during either of the last
2 calendar years. See Pub. 969 for
details.

Archer MSA
Generally, an Archer MSA is a medical
savings account set up exclusively for
paying the qualified medical expenses of
the account holder or the account holder’s
spouse or dependent(s).

Qualified Medical Expenses
Generally, qualified medical expenses for
Archer MSA purposes are unreimbursed
medical expenses that could otherwise be
deducted on Schedule A (Form 1040).
See the Instructions for Schedule A and
Pub. 502, Medical and Dental Expenses
(Including the Health Coverage Tax
Credit). However, you cannot treat
insurance premiums as qualified medical
expenses unless the premiums are for:

• Long-term care (LTC) insurance,
• Health care continuation coverage, or
• Health care coverage while receiving
unemployment compensation under
federal or state law.

High Deductible Health Plan
An HDHP is a health plan that meets the
following requirements.
Cat. No. 24188L

Other Health Coverage
If you have an Archer MSA, you (and your
spouse, if you have family coverage)
cannot have any health coverage other
than an HDHP. But your spouse can have
health coverage other than an HDHP if
you are not covered by that plan.
Exceptions. You can have additional
insurance that provides benefits only for:
• Liabilities under workers’ compensation
laws, tort liabilities, or liabilities arising
from the ownership or use of property,
• A specific disease or illness, or
• A fixed amount per day (or other
period) of hospitalization.
You can also have coverage (either
through insurance or otherwise) for
accidents, disability, dental care, vision
care, or long-term care.

Disabled
An individual generally is considered
disabled if he or she is unable to engage
in any substantial gainful activity due to a
physical or mental impairment which can
be expected to result in death or to
continue indefinitely.

Death of Account Holder
If the account holder’s surviving spouse is
the designated beneficiary, the Archer
MSA is treated as if the surviving spouse
were the account holder. The surviving
spouse completes Form 8853 as though
the Archer MSA belonged to him or her.
If the designated beneficiary is not the
account holder’s surviving spouse, or
there is no designated beneficiary, the
account ceases to be an Archer MSA as
of the date of death. The beneficiary
completes Form 8853 as follows.
• Enter “Death of Archer MSA account
holder” across the top of Form 8853.
• Enter the name(s) shown on your tax
return and your SSN in the spaces

Page 2 of 8

Instructions for Form 8853

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provided at the top of the form and skip
Part II.
• On line 8a, enter the fair market value
of the Archer MSA as of the date of
death.
• On line 9, for a beneficiary other than
the estate, enter qualified medical
expenses incurred by the account holder
before the date of death that you paid
within 1 year after the date of death.
• Complete the rest of Part III.
If the account holder’s estate is the
beneficiary, the value of the Archer MSA
as of the date of death is included in the
account holder’s final income tax return.
Complete Form 8853 as described above,
except you should complete Part II, if
applicable.
The distribution is not subject to the
additional 15% tax. Report any earnings
on the account after the date of death as
income on your tax return.

Deemed Distributions From Archer
MSAs
The following situations result in deemed
distributions from your Archer MSA.
• You engaged in any transaction
prohibited by section 4975 with respect to
any of your Archer MSAs, at any time in
2005. Your account ceases to be an
Archer MSA as of January 1, 2005, and
you must include the fair market value of
all assets in the account as of January 1,
2005, on line 8a.
• You used any portion of any of your
Archer MSAs as security for a loan at any
time in 2005. You must include the fair
market value of the assets used as
security for the loan as income on Form
1040, line 21.
Any deemed distribution will not be
treated as used to pay qualified medical
expenses. Generally, these distributions
are subject to the additional 15% tax.

Part I—General
Information
Complete this part if contributions were
made for 2005 by:
• You (or your employer) to your Archer
MSA, or
• Your spouse (or his or her employer) to
your spouse’s Archer MSA (if you are
filing a joint return).

Lines 1a and 2a
Check “Yes” on line 1a if you or your
employer made contributions to your
Archer MSA for 2005, including
contributions for 2005 made from January
1, 2006, through April 17, 2006.
Otherwise, check the “No” box on line 1a.
Check “Yes” on line 2a if you are filing
a joint return and your spouse (or your
spouse’s employer) made contributions to
your spouse’s Archer MSA for 2005,

including contributions for 2005 made
from January 1, 2006, through April 17,
2006. Otherwise, check the “No” box on
line 2a.

Lines 1b and 2b
Check “Yes” on line 1b or 2b only if the
account holder is considered previously
uninsured.
An account holder is considered
previously uninsured if the HDHP
coverage began after June 30, 1996, and
the account holder has:
1. Self-only coverage under an HDHP
and did not have any health plan
coverage at any time during the 6-month
period before coverage under the HDHP
began, or
2. Family coverage under an HDHP
and neither the account holder nor the
account holder’s spouse had any health
plan coverage at any time during the
6-month period before coverage under
the HDHP began.
In determining whether an account
holder is previously uninsured, disregard
any health insurance that is permitted in
addition to the HDHP. See Other Health
Coverage on page 1.

Lines 1c and 2c
If covered by a self-only HDHP and a
family HDHP, indicate which plan was in
effect longer during the year.

Part II—Archer MSA
Contributions and
Deductions
Use Part II to figure:
• Your Archer MSA deduction,
• Any excess contributions you made,
and
• Any excess contributions made by an
employer (see Excess Employer
Contributions on page 4).

Figuring Your Archer MSA
Deduction
The amount you can deduct for Archer
MSA contributions is limited by:
• The applicable portion of the HDHP’s
annual deductible (line 5), and
• Your compensation from the employer
maintaining the HDHP (line 6).
Any employer contributions made to
your Archer MSA prevent you from
making deductible contributions. See
Employer Contributions to an Archer MSA
on this page. Also, if you or your spouse
made contributions in addition to any
employer contributions, you may have to
pay an additional tax. See Excess
Contributions You Make on page 4.
You cannot deduct any contributions
you made after you became enrolled in
Medicare. Also, you cannot deduct

-2-

contributions if you can be claimed as a
dependent on someone else’s 2005 tax
return.

Employer Contributions to an
Archer MSA
If an employer made contributions to your
Archer MSA, you are not entitled to a
deduction. If you and your spouse are
covered under an HDHP with family
coverage and an employer made
contributions to either of your Archer
MSAs, neither you nor your spouse are
allowed to make deductible contributions
to an Archer MSA. If you and your spouse
each have an Archer MSA with self-only
coverage and only one of you received
employer contributions to an Archer MSA,
the other spouse is allowed to make
deductible contributions to an Archer
MSA.

How To Complete Part II
Complete lines 3 through 7 as instructed
on the form unless 1 or 2 below applies.
1. If employer contributions to an
Archer MSA prevent you from taking a
deduction for amounts you contributed to
your Archer MSA, complete Part II as
follows.
a. Complete lines 3 and 4.
b. Skip lines 5 and 6.
c. Enter -0- on line 7.
d. If line 4 is more than zero, see
Excess Contributions You Make
on page 4.
2. If you and your spouse have more
than one Archer MSA, complete Part II as
follows.
a. If either spouse has an HDHP with
family coverage, you both are treated as
having only the family coverage plan.
Disregard any plans with self-only
coverage.
b. If both spouses have HDHPs with
family coverage, you both are treated as
having only the family coverage plan with
the lowest annual deductible.
c. If both spouses have HDHPs with
self-only coverage, complete a separate
Form 8853, Section A, Part II, for each
spouse. Enter “statement” across the top
of each Form 8853, fill in the name and
SSN, and complete Part II. Next, add
lines 3, 4, and 7 from the two statement
Forms 8853 and enter those totals on the
respective lines of the controlling Form
8853 (the combined Form 8853 for both
spouses). Do not complete lines 5 and 6
of the controlling Form 8853. Attach the
two statement Forms 8853 to your tax
return after the controlling Form 8853.

Line 3
Employer Contributions
Employer contributions include any
amount an employer contributes to any

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Instructions for Form 8853

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Archer MSA for you or your spouse for
2005. These contributions should be
shown in box 12 of Form W-2 with code
R. If your employer made excess
contributions, you may have to report the
excess as income. See Excess Employer
Contributions on page 4 for details.

Line 4
Do not include amounts rolled over from
another Archer MSA. See Rollovers on
page 4.

Line 5 Limitation Chart and Worksheet
Go through this chart for each month of 2005.
See the instructions for line 5 on this page.
(Keep for your records)
Start Here
Were you enrolled in Medicare for
the month?
No

Line 5
Go through the chart at the top of the Line
5 Limitation Chart and Worksheet on this
page for each month of 2005. Enter the
result on the worksheet next to the
corresponding month.
If eligibility and coverage of both
TIP you and your spouse did not
change from one month to the
next, enter the same number you entered
for the previous month. If eligibility and
coverage did not change during the entire
year, figure the number for January only,
and enter this amount on Form 8853, line
5.
More than one HDHP. If you and your
spouse had more than one HDHP on the
first of the month and one of the plans
provides family coverage, use the Family
coverage rules on the chart and disregard
any plans with self-only coverage. If you
and your spouse both have HDHPs with
family coverage on the first of the month,
you both are treated as having only the
family coverage plan with the lowest
annual deductible.
Married filing separately. If you have an
HDHP with family coverage and are
married filing separately, enter only
37.5% (.375) (one-half of 75%) of the
annual deductible on the worksheet; or, if
you and your spouse agree to divide the
75% of the annual deductible in a
different manner, enter your share.

䊲

Were you an eligible individual (see
page 1 of the instructions) on the
first day of the month?

䊲
䊳

Enter -0- on the line
below for the month.

Yes
䊲

What type of coverage did your HDHP provide on the first day of the
month? If you had more than one HDHP, see instructions on this page.

Self-only coverage

Family coverage

Enter annual deductible
(must be at least $1,750
but not more than $2,650)

Enter annual deductible
(must be at least $3,500
but not more than $5,250)

$
䊲

䊲

Enter 65% (.65) of the annual
deductible on the line below for the
month.

Enter 75% (.75) of the annual
deductible on the line below for the
month. If married filing separately,
see instructions on this page.

Amount from
chart above

Month in 2005
January
February
March
April

Line 6

May

Compensation

June

Compensation includes wages, salaries,
professional fees, and other pay you
receive for services you perform. It also
includes sales commissions,
commissions on insurance premiums, pay
based on a percentage of profits, tips,
and bonuses. Generally, these amounts
are included on the Form(s) W-2 you
receive from your employer(s).
Compensation also includes net earnings
from self-employment, but only for a trade
or business in which your personal
services are a material income-producing
factor. Generally, this amount is shown on
the Schedule SE (Form 1040) you
complete for your business or farm.
Compensation does not include any
amounts received as a pension or annuity

Yes

July
August
September
October
November
December
Total for all months
Limitation. Divide the total by 12. Enter here and on line 5

-3-

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Instructions for Form 8853

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and does not include any amount
received as deferred compensation.

Line 7
If you (or your employer) contributed
more to your Archer MSA than is
allowable, you may have to pay an
additional tax on the excess contributions.
Figure the excess contributions using the
instructions below. See Form 5329,
Additional Taxes on Qualified Plans
(Including IRAs) and Other Tax-Favored
Accounts, to figure the additional tax.

Excess Contributions You Make
To figure your excess contributions,
subtract your deductible contributions
(line 7) from your actual contributions (line
4). However, you can withdraw some or
all of your excess contributions for 2005
and they will be treated as if they had not
been contributed if:
• You make the withdrawal by the due
date, including extensions, of your 2005
tax return (but see the Note below),
• You do not claim a deduction for the
amount of the withdrawn contributions,
and
• You also withdraw any income earned
on the withdrawn contributions and
include the earnings in “Other income” on
your tax return for the year you withdraw
the contributions and earnings.

Excess Employer Contributions
Excess employer contributions are the
excess, if any, of your employer’s
contributions over the smaller of (a) your
limitation on line 5, or (b) your
compensation from the employer(s) who
maintained your HDHP (line 6). If the
excess 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 2005 and they
will be treated as if they had not been
contributed if:
• You make the withdrawal by the due
date, including extensions, of your 2005
tax return (but see the Note below),
• You do not claim an exclusion from
income for the amount of the withdrawn
contributions, and
• You also withdraw any income earned
on the withdrawn contributions and
include the earnings in “Other income” on
your tax return for the year you withdraw
the contributions and earnings.
Note. If you timely filed your return
without withdrawing the excess
contributions, you can still make the
withdrawal no later than 6 months after
the due date of your tax return, excluding
extensions. If you do, file an amended
return with “Filed pursuant to section
301.9100-2” written at the top. Include an
explanation of the withdrawal. Make all
necessary changes on the amended

return (for example, if you reported the
contributions as excess contributions on
your original return, include an amended
Form 5329 reflecting that the withdrawn
contributions are no longer treated as
having been contributed).

Part III—Archer MSA
Distributions
Line 8a
Enter the total distributions you and your
spouse received in 2005 from all Archer
MSAs. These amounts should be shown
in box 1 of Form 1099-SA.

Line 8b
Include on line 8b any distributions you
received in 2005 that were rolled over.
See Rollovers below. Also include any
excess contributions (and the earnings on
those excess contributions) included on
line 8a that were withdrawn by the due
date, including extensions, of your return.
See the instructions for line 7 on this
page.

Rollovers
A rollover is a tax-free distribution
(withdrawal) of assets from one Archer
MSA that is reinvested in another Archer
MSA or a health savings account.
Generally, you must complete the rollover
within 60 days following the distribution.
You can make only one rollover
contribution to an Archer MSA during a
1-year period. See Pub. 590, Individual
Retirement Arrangements (IRAs), for
more details and additional requirements
regarding rollovers.
Note. If you instruct the trustee of your
Archer MSA to transfer funds directly to
the trustee of another Archer MSA, the
transfer is not considered a rollover.
There is no limit on the number of these
transfers. Do not include the amount
transferred in income, deduct it as a
contribution, or include it as a distribution
on line 8a.

Line 9
In general, include on line 9 distributions
from all Archer MSAs in 2005 that were
used for the qualified medical expenses
(see page 1) of:
• Yourself and your spouse.
• All dependents you claim on your tax
return.
• Any person you could have claimed as
a dependent on your return except that
person received $3,200 or more of gross
income or filed a joint return.
• Any person you could have claimed as
a dependent except that you, or your
spouse if filing jointly, were claimed as a
dependent on someone else’s 2005
return.

-4-

However, if a contribution was made to
an Archer MSA in 2005 (by you or your
employer), do not include on line 9
withdrawals from an Archer MSA if the
individual for whom the expenses were
incurred was not covered by an HDHP or
was covered by a plan that was not an
HDHP (other than the exceptions listed
on page 1) at the time the expenses were
incurred.
Example. In 2005, you were covered
by an HDHP with self-only coverage and
your spouse was covered by a health
plan that was not an HDHP. You made
contributions to an Archer MSA for 2005.
You cannot include on line 9 withdrawals
made from the Archer MSA to pay your
spouse’s medical expenses incurred in
2005 because your spouse was covered
by a plan that was not an HDHP.

CAUTION

You cannot take a deduction on
Schedule A (Form 1040) for any
amount you include on line 9.

Lines 11a and 11b
Additional 15% Tax
Archer MSA distributions included in
income (line 10) are subject to an
additional 15% tax unless one of the
following exceptions apply.

Exceptions to the Additional 15%
Tax
The additional 15% tax does not apply to
distributions made on or after the date
that the account holder —
• Dies,
• Becomes disabled (see page 1), or
• Turns age 65.
If any of the exceptions apply to any of
the distributions included on line 10,
check the box on line 11a. Enter on line
11b only 15% (.15) of any amount
included on line 10 that does not meet
any of the exceptions.
Example 1. You turned age 66 in
2005 and had no Archer MSA during
2005. Your spouse turned age 63 in 2005
and received a distribution from an Archer
MSA that is included in income. Do not
check the box on line 11a because your
spouse (the account holder) did not meet
the age exception for the distribution.
Enter 15% of the amount from line 10 on
line 11b.
Example 2. Both you and your
spouse received distributions from your
Archer MSAs in 2005 that are included in
income. You were age 65 at the time you
received the distributions and your
spouse was age 63 when he or she
received the distributions. Check the box
on line 11a because the additional 15%
tax does not apply to the distributions you
received (because you met the age
exception). However, the additional 15%
tax does apply to your spouse’s

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distributions. Enter on line 11b only 15%
of the amount of your spouse’s
distributions included in line 10.
Example 3. You turned age 65 in
2005. You received distributions that are
included in income both before and after
you turned age 65. Check the box on line
11a because the additional 15% tax does
not apply to the distributions made after
the date you turned age 65. However, the
additional 15% tax does apply to the
distributions made on or before the date
you turned age 65. Enter on line 11b,
15% of the amount of these distributions
included in line 10.

Section B—Medicare
Advantage MSA
Distributions
Complete Section B if you (or your
spouse, if filing jointly) received
distributions from a Medicare Advantage
MSA in 2005. If both you and your spouse
received distributions, complete a
separate Form 8853, Section B, for each
spouse. Enter “statement” across the top
of each Form 8853, fill in the name and
SSN, and complete Section B. Next, add
lines 12, 13, 14, and 15b from the two
statement Forms 8853 and enter those
totals on the respective lines of the
controlling Form 8853 (the combined
Form 8853 for both spouses). If either
spouse checked the box on line 15a of
the statement Form 8853, check the box
on the controlling Form 8853. Attach the
two statement Forms 8853 to your tax
return after the controlling Form 8853.

Medicare Advantage MSA
A Medicare Advantage MSA is an Archer
MSA designated as a Medicare
Advantage MSA to be used solely to pay
the qualified medical expenses of the
account holder. To be eligible for a
Medicare Advantage MSA, you must be
enrolled in Medicare and have an HDHP

that meets the Medicare guidelines.
Contributions to the account can be made
only by Medicare. The contributions and
any earnings, while in the account, are
not taxable to the account holder. A
distribution used exclusively to pay for the
qualified medical expenses of the account
holder is not taxable. Distributions that
are not used for qualified medical
expenses of the account holder are
included in income and also may be
subject to a penalty.

Death of Account Holder
If the account holder’s surviving spouse is
the designated beneficiary, the Medicare
Advantage MSA is treated as a regular
Archer MSA (not a Medicare Advantage
MSA) of the surviving spouse for
distribution purposes. Follow the
instructions in Section A for Death of
Account Holder that begin on page 1.
If the designated beneficiary is not the
account holder’s surviving spouse, or
there is no designated beneficiary, the
account ceases to be an MSA as of the
date of death. The beneficiary completes
Form 8853 as follows.
• Enter “Death of Medicare Advantage
MSA account holder” across the top of
Form 8853.
• Enter the name(s) shown on your tax
return and your SSN in the spaces
provided at the top of the form. Skip
Section A.
• On line 12, enter the fair market value
of the Medicare Advantage MSA as of the
date of death.
• On line 13, for a beneficiary other than
the estate, enter qualified medical
expenses incurred by the account holder
before the date of death that you paid
within 1 year after the date of death.
• Complete the rest of Section B.
If the account holder’s estate is the
beneficiary, the value of the Medicare
Advantage MSA as of the date of death is
included in the account holder’s final
income tax return.

The distribution is not subject to the
additional 50% tax. Report any earnings
on the account after the date of death as
income on your tax return.

Line 12
Enter the total distributions you received
in 2005 from all Medicare Advantage
MSAs. These amounts should be shown
in box 1 of Form 1099-SA. This amount
should not include any erroneous
contributions made by Medicare (or any
earnings on the erroneous contributions)
or any amounts from a trustee-to-trustee
transfer from one Medicare Advantage
MSA to another Medicare Advantage
MSA of the same account holder.

Line 13
Enter the total distributions from all
Medicare Advantage MSAs in 2005 that
were used for your qualified medical
expenses (see page 1).

CAUTION

You cannot take a deduction on
Schedule A (Form 1040) for any
amount you include on line 13.

Lines 15a and 15b
Additional 50% Tax
Medicare Advantage MSA distributions
included in income (line 14) may be
subject to an additional 50% tax unless
one of the following exceptions applies.

Exceptions to the Additional 50%
Tax
The additional 50% tax does not apply to
distributions made on or after the date
that the account holder —
• Dies, or
• Becomes disabled (see page 1).
If either of the exceptions applies to any
of the distributions included on line 14,
check the box on line 15a. Next, if either
of the exceptions applies to all the
distributions included on line 14, enter -0on line 15b. Otherwise, complete the
worksheet on page 5 to figure the amount

Additional 50% Tax Worksheet—Line 15b

(Keep for Your Records)

1. Enter the total distributions included on Form 8853, line 14, that do not meet either of the exceptions
to the additional 50% tax
2. Did you have a Medicare Advantage MSA on December 31, 2004?
No.
Enter one-half of line 1 on Form 8853, line 15b.
Yes. Enter the value of your Medicare Advantage MSA on December 31, 2004 2.
Enter the amount of the annual deductible for your HDHP policy
3.
on January 1, 2005
4.
Multiply line 3 by 60% (.60)
Subtract line 4 from line 2. If zero or less, enter -0Subtract line 5 from line 1. If zero or less, enter -0Enter one-half of line 6 here and on Form 8853, line 15b

STOP

3.
4.
5.
6.
7.

-5-

5.
6.
7.

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Filing Requirements for Section C
Go through this chart for each insured person for
whom you received long-term care (LTC) payments.
See Definitions that begin on this page.
Start Here
Did you (or your spouse, if
filing jointly) receive
payments in 2005 made on
a per diem or other periodic
basis under an LTC
insurance contract?

䊳

Yes

Were any of those
payments made
under a qualified LTC
insurance contract?

䊳

Yes

Complete all of
Section C

No
䊲

䊲

Did you (or your spouse, if
filing jointly) receive any
accelerated death benefits
in 2005 from a life
insurance policy that were
made on a per diem or
other periodic basis?

Did you (or your spouse, if
filing jointly) receive any
accelerated death benefits in
2005 from a life insurance
policy that were made on a
per diem or other periodic
basis?

䊳

Complete only lines
16a, 16b, and 19 of
Section C

Yes
䊲

Yes

䊳

Were any of the payments
paid on behalf of a
chronically ill (not terminally
ill) individual?

䊳

Complete only lines 16a,
16b, 17, 18, 19 (if
applicable), and 28 of
Section C

Yes
䊲

Do not complete
Section C

of the additional 50% tax to enter on line
15b.

Section C—Long-Term
Care (LTC) Insurance
Contracts
See Filing Requirements for Section C
above.

Definitions
Policyholder
The policyholder is the person who owns
the proceeds of the LTC insurance
contract, life insurance contract, or viatical
settlement, and also can be the insured
individual. The policyholder is required to
report the income, even if payment is
assigned to a third party or parties. In the
case of a group contract, the certificate

䊲

Complete all of Section C

holder is considered to be the
policyholder.

Qualified LTC Insurance Contract
A qualified LTC insurance contract is a
contract issued:
• After December 31, 1996, that meets
the requirements of section 7702B,
including the requirement that the insured
must be a chronically ill individual
(defined on this page), or
• Before January 1, 1997, that met state
law requirements for LTC insurance
contracts at the time the contract was
issued and has not been changed
materially.
In general, amounts paid under a
qualified LTC insurance contract are
excluded from your income. However, if
you receive per diem payments (defined
below), the amount you can exclude is
limited.

-6-

Per Diem Payments
Per diem payments are payments of a
fixed amount made on a periodic basis
without regard to actual expenses
incurred. Box 3 of Form 1099-LTC should
indicate whether payments were per diem
payments.

Chronically Ill Individual
A chronically ill individual is someone who
has been certified (at least annually) by a
licensed health care practitioner as —
• Being unable to perform at least two
activities of daily living (ADLs) (eating,
toileting, transferring, bathing, dressing,
and continence), without substantial
assistance from another individual, for at
least 90 days, due to a loss of functional
capacity, or
• Requiring substantial supervision to
protect the individual from threats to

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health and safety due to severe cognitive
impairment.

Accelerated Death Benefits
Generally, amounts paid as accelerated
death benefits under a life insurance
contract or under certain viatical
settlements are fully excludable from your
gross income if the insured is a terminally
ill individual (defined below). Accelerated
death benefits paid with respect to an
insured individual who is chronically ill
generally are excludable from your gross
income to the same extent as they would
be under a qualified LTC insurance
contract.

in 2005 under a qualified LTC insurance
contract or as accelerated death benefits
with respect to the insured listed on line
16a. See Multiple Payees on this page for
details.

Method 1 —Contract Period
Under this method your LTC period is the
same period as that used by the
insurance company under the contract to
compute the benefits it pays you. For
example, if the insurance company
computes your benefits on a daily basis,
your LTC period is 1 day.

A terminally ill individual is any individual
who has been certified by a physician as
having an illness or physical condition
that can reasonably be expected to result
in death within 24 months.

If you choose this method for
defining the LTC period(s) and
CAUTION different LTC insurance contracts
for the same insured use different
contract periods, then all such LTC
contracts must be treated as computing
benefits on a daily basis.

Line 17

Method 2 —Equal Payment Rate

Special rules apply in determining the
taxable payments if other individuals
received per diem payments under a
qualified LTC insurance contract or as
accelerated death benefits with respect to
the insured listed on line 16a. See
Multiple Payees on this page for details.

Under this method, your LTC period is the
period during which the insurance
company uses the same payment rate to
compute your benefits. For example, you
have two LTC periods if the insurance
contract computes payments at a rate of
$175 per day from March 1, 2005,
through May 31, 2005, and then at a rate
of $195 per day from June 1, 2005,
through December 31, 2005. The first
LTC period is 92 days (from March 1
through May 31) and the second LTC
period is 214 days (from June 1 through
December 31).

Terminally Ill Individual

Line 20
If you have more than one LTC
period, you must separately
CAUTION calculate the taxable amount of
the payments received during each LTC
period. To do this, complete lines 20
through 28 on separate Sections C for
each LTC period. Enter the total on line
28 from each separate Section C on the
Form 8853 that you attach to your tax
return. See the instructions for line 23 on
this page for the LTC period.

Line 21
Enter the total accelerated death benefits
you received with respect to the insured
listed on line 16a. These amounts
generally are shown in box 2 of Form
1099-LTC. Include only amounts you
received while the insured was a
chronically ill individual. Do not include
amounts you received while the insured
was a terminally ill individual. If the
insured was redesignated from
chronically ill to terminally ill in 2005, only
include on line 21 payments received
before the insured was certified as
terminally ill.

Line 23
The number of days in your LTC period
depends on which method you choose to
define the LTC period. Generally, you can
choose either the Contract Period method
or the Equal Payment Rate method.
However, special rules apply if other
persons also received per diem payments

You can choose this method even if
you have more than one qualified LTC
insurance contract covering the same
period. For example, you have one
insurance contract that pays $100 per day
from March 1, 2005, through December
31, 2005, and you have a second
insurance contract that pays $1,500 per
month from March 1, 2005, through
December 31, 2005. You have one LTC
period because each payment rate does
not vary during the LTC period of March 1
through December 31. However, you
have two LTC periods if the facts are the
same except that the second insurance
contract did not begin making payments
until May 1, 2005. The first LTC period is
61 days (from March 1 through April 30)
and the second LTC period is 245 days
(from May 1 through December 31).

Line 24
Qualified LTC services are necessary
diagnostic, preventive, therapeutic,
curing, treating, mitigating, and
rehabilitative services, and maintenance
or personal care services required to treat
a chronically ill individual under a plan of
care prescribed by a licensed health care
practitioner.

-7-

Line 26
Enter the reimbursements you received or
expect to receive through insurance or
otherwise for qualified LTC services
provided for the insured for LTC periods
in 2005. Box 3 of Form 1099-LTC should
indicate whether the payments were
made on a reimbursement basis.
Generally, do not include on line
26 any reimbursements for
CAUTION qualified LTC services you
received under a contract issued before
August 1, 1996. However, you must
include reimbursements if the contract
was exchanged or modified after July 31,
1996, to increase per diem payments or
reimbursements.

Multiple Payees
If you checked “Yes” on lines 17 and 18
and the only payments you received were
accelerated death benefits that were paid
because the insured was terminally ill,
skip lines 19 through 27 and enter -0- on
line 28.
In all other cases in which you
checked “Yes” on line 17, attach a
statement duplicating lines 20 through 28
of the form. This statement should show
the aggregate computation for all persons
who received per diem payments under a
qualified LTC insurance contract or as
accelerated death benefits because the
insured was chronically ill. Each person
must use the same LTC period. If all the
recipients of payments do not agree on
which LTC period to use, the contract
period method must be used.
After completing the statement,
determine your share of the per diem
limitation and any taxable payments. The
per diem limitation is allocated first to the
insured to the extent of the total payments
the insured received. If the insured files a
joint return and the insured’s spouse is
one of the policyholders, the per diem
limitation is allocated first to them to the
extent of the payments they both
received. Any remaining limitation is
allocated among the other policyholders
pro rata based on the payments they
received in 2005. The statement showing
the aggregate computation must be
attached to the Form 8853 for each
person who received a payment.
Enter your share of the per diem
limitation and the taxable payments on
lines 27 and 28 of your individual Form
8853. Leave lines 23 through 26 blank.

Example 1
Mrs. Smith was chronically ill throughout
2005 and received 12 monthly payments
on a per diem basis from a qualified LTC
insurance contract. She was paid $2,000
per month ($24,000 total). Mrs. Smith
incurred expenses for qualified LTC
services of $100 per day ($36,500) and

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was reimbursed for one-half of those
expenses ($18,250). She uses the equal
payment rate method and therefore has a
single benefit period for 2005 (January
1 – December 31). Mrs. Smith completes
Form 8853, lines 22 through 28, as
follows.
Line
22

Amount
$24,000 ($2,000 x 12 mos.)

$87,600 ($240 x 365 days)

$36,500 ($100 x 365 days)

$87,600

$18,250 ($50 x 365 days)

$69,350

$-0-

Example 2
The facts are the same as in Example 1,
except Mrs. Smith’s son, Sam, and
daughter, Deborah, each also own a
qualified LTC insurance contract under
which Mrs. Smith is the insured. Neither
Sam nor Deborah incurred any costs for
qualified LTC services for Mrs. Smith in
2005. From July 1, 2005, through
December 31, 2005, Sam received per
diem payments of $2,700 per month
($16,200 total) and Deborah received per
diem payments of $1,800 per month
($10,800 total). Mrs. Smith, Sam, and
Deborah agree to use the equal payment
rate method to determine their LTC
periods.
There are two LTC periods. The first is
181 days (from January 1 through June
30) during which the per diem payments
were $2,000 per month. The second is
184 days (from July 1 through December
31) during which the aggregate per diem
payments were $6,500 per month ($2,000
under Mrs. Smith’s contract + $2,700
under Sam’s contract + $1,800 under
Deborah’s contract).
An aggregate statement must be
completed for the second LTC period and
attached to Mrs. Smith’s, Sam’s, and
Deborah’s forms.
Step 1. They complete a statement for
Mrs. Smith for the first LTC period as
follows.
Line

$34,390

$ -0-

Deborah’s Form 8853:

Step 2. They complete the aggregate
statement for the second LTC period as
follows.
Line

Amount

$39,000 ($6,500 x 6 mos.)

$44,160 ($240 x 184 days)

$18,400 ($100 x 184 days)

$44,160

$9,200 ($50 x 184 days)

$34,960

$4,040

Step 3. They allocate the aggregate per
diem limitation of $34,960 on line 27
among Mrs. Smith, Sam, and Deborah.
Because Mrs. Smith is the insured, the
per diem limitation is allocated first to her
to the extent of the per diem payments
she received during the second LTC
period ($12,000). The remaining per diem
limitation of $22,960 is allocated between
Sam and Deborah.
Allocation ratio to Sam: 60% of the
remaining limitation ($13,776) is allocated
to Sam because the $16,200 he received
during the second LTC period is 60% of
the $27,000 received by both Sam and
Deborah during the second LTC period.
Allocation ratio to Deborah: 40% of
the remaining limitation ($9,184) is
allocated to Deborah because the
$10,800 she received during the second
LTC period is 40% of the $27,000
received by both Sam and Deborah
during the second LTC period.
Step 4. Mrs. Smith, Sam, and Deborah
each complete Form 8853 as follows.
Mrs. Smith’s Form 8853:
Line

1st LTC
Period

2nd LTC
Period

Form 8853

$12,000

$24,000

$34,390

$12,000

$46,390

$ -0-

$-0-

Sam’s Form 8853:

Amount
Line

1st LTC
Period

2nd LTC
Period

Form 8853

$12,000 ($2,000 x 6 mos.)

$43,440 ($240 x 181 days)

$-0-

$16,200

$18,100 ($100 x 181 days)

$-0-

$13,776

$43,440

$-0-

$2,424

$9,050 ($50 x 181 days)

-8-

Line

1st LTC
Period

2nd LTC
Period

Form 8853

$-0-

$10,800

$-0-

$9,184

$-0-

$1,616

Paperwork Reduction Act Notice. We
ask for the information on this form to
carry out the Internal Revenue laws of the
United States. You are required to give us
the information. We need it to ensure that
you are complying with these laws and to
allow us to figure and collect the right
amount of tax.
You are not required to provide the
information requested on a form that is
subject to the Paperwork Reduction Act
unless the form displays a valid OMB
control number. Books or records relating
to a form or its instructions must be
retained as long as their contents may
become material in the administration of
any Internal Revenue law. Generally, tax
returns and return information are
confidential, as required by section 6103.
The average time and expenses
required to complete and file this form will
vary depending on individual
circumstances. For estimated averages,
see the instructions for your income tax
return.
If you have suggestions for making this
form simpler, we would be happy to hear
from you. See the instructions for your
income tax return.

File Type	application/pdf
File Title	2005 Form 1040
Subject	U.S. Individual Income Tax Return
Author	SE:W:CAR:MP
File Modified	2006-12-30
File Created	2006-12-30