8853 Archer MSAs and Long-Term Care Insurance Contracts

Form

8853

Department of the Treasury
Internal Revenue Service (99)

OMB No. 1545-0074

Archer MSAs and
Long-Term Care Insurance Contracts
©

Attach to Form 1040 or Form 1040NR.

Name(s) shown on return

©

2008
Attachment
Sequence No.

See separate instructions.

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

39

©

Section A. Archer MSAs. If you have only a Medicare Advantage MSA, skip Section A and complete Section B.
Part I
General Information. See page 2 of the instructions.
Yes No
1a
b
c
2a
b
c

Did you or your employer make contributions to your Archer MSA for 2008?
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 2008?
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

Total employer contributions to your Archer MSA(s) for 2008

4

Archer MSA contributions you made for 2008, including direct deposits of economic stimulus
payments and those made from January 1, 2009, through April 15, 2009, that were for 2008. Do
not include rollovers (see page 3 of the instructions)
Limitation from the worksheet on page 3 of the instructions
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
the high deductible health plan was established.)

7

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.

3

5
6

1a
1b

4
5

6

Archer MSA deduction. Enter the smallest of line 4, 5, or 6 here. Also include this amount on
Form 1040, line 36, or Form 1040NR, line 34. On the dotted line next to Form 1040, line 36, or
Form 1040NR, line 34, enter “MSA” and the amount.
7
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 2008 from all Archer MSAs (see page 4 of the instructions)

8a

b Distributions included on line 8a that you rolled over to another Archer MSA or a health savings
account. Also include any portion of a direct deposit of an economic stimulus payment and
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

10

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 5 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 61, or Form 1040NR, line 57. On the dotted line next to Form 1040, line 61, or
Form 1040NR, line 57, enter “MSA” and the amount

10

11b

Section B. Medicare Advantage MSA Distributions. If you are filing jointly and both you and your spouse received
distributions in 2008 from a Medicare Advantage MSA, complete a separate Section B for each spouse
(see page 5 of the instructions).
12
13

Total distributions you received in 2008 from all Medicare Advantage MSAs (see page 5 of the instructions)
Unreimbursed qualified medical expenses (see page 6 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
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50% Tax (see page 6 of the instructions), check here
b Additional 50% tax (see page 6 of the instructions). Also include this amount in the total on
Form 1040, line 61, or Form 1040NR, line 57. On the dotted line next to Form 1040, line 61, or
Form 1040NR, line 57, enter “Med MSA” and the amount

12
13

14

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

Cat. No. 24091H

14

15b
Form

8853

(2008)

Form 8853 (2008)

Attachment Sequence No.

Name of policyholder (as shown on Form 1040)

39

Page

2

Social security number
of policyholder ©

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

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b Social security number of insured

©

In 2008, 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?

18

Was the insured a terminally ill individual?
Note: If “Yes” and the only payments you received in 2008 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.

19

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
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.
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)

20
21

22

23
24

25
26

27
28

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.
Multiply $270 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.

Yes

No

Yes

No

19

20
21
22

23
24
25
26

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

27

28
Form

8853

(2008)