Form 8853 Archer MSAa and Long-Term Care Insurance Contracts

Form

8853

Department of the Treasury
Internal Revenue Service (99)
Name(s) shown on return

Archer MSAs and
Long-Term Care Insurance Contracts
©

Attach to Form 1040 or Form 1040NR.

© See

OMB No. 1545-0074

2009

Attachment
Sequence No. 39

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.
Part I
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 I for each spouse.
1
2

1
Total employer contributions to your Archer MSA(s) for 2009 . . . .
Archer MSA contributions you made for 2009, including those made from January 1, 2010,
through April 15, 2010, that were for 2009. Do not include rollovers (see page 2 of the instructions)

3
4

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.) . . . . . . . . . . . . . . . . .

2
3

4
Archer MSA deduction. Enter the smallest of line 2, 3, or 4 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 . . . . . . . . . . . . . . . .
5
Caution: If line 2 is more than line 5, you may have to pay an additional tax (see page 3 of the instructions).

5

Part II
6a

Archer MSA Distributions

Total distributions you and your spouse received in 2009 from all Archer MSAs (see page 4 of the
instructions) . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

b Distributions included on line 6a 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included on line 6a that were withdrawn by the due date of your return (see page 4 of the
instructions) . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
c
7
8

9a

Subtract line 6b from line 6a
. . . . . . . . . . . . . . . . . . . . . . .
Unreimbursed qualified medical expenses (see page 4 of the instructions) . . . . . . . .
Taxable Archer MSA distributions. Subtract line 7 from line 6c. 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 . . . . . . . . . . . . . . . . .
If any of the distributions included on line 8 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 8 that are subject to the additional 15% tax. Also include this amount in the total on Form
1040, line 60, or Form 1040NR, line 57. On the dotted line next to Form 1040, line 60, or Form
1040NR, line 57, enter “MSA” and the amount
. . . . . . . . . . . . . . . . .

6a

6b
6c
7

8

9b

Section B. Medicare Advantage MSA Distributions. If you are filing jointly and both you and your spouse received
distributions in 2009 from a Medicare Advantage MSA, complete a separate Section B for each spouse (see
page 4 of the instructions).
10
11
12

13a

Total distributions you received in 2009 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 11 from line 10. 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 . . . . . . . . . .
If any of the distributions included on line 12 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 60, or Form 1040NR, line 57. On the dotted line next to Form 1040, line 60, or Form
1040NR, line 57, enter “Med MSA” and the amount . . . . . . . . . . . . . . . .
For Paperwork Reduction Act Notice, see page 8 of the instructions.

Cat. No. 24091H

10
11

12

13b
Form 8853 (2009)

Form 8853 (2009)
Name of policyholder (as shown on Form 1040)

Attachment Sequence No.

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 .
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b Social security number of insured ©
Name of insured ©
In 2009, 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? . . . . . . . . . . . . . . . . . . . . . . .

16

Was the insured a terminally ill individual? . . . . . . . . . . . . . . . . . . . . . .
Note: If “Yes” and the only payments you received in 2009 were accelerated death benefits that were paid
to you because the insured was terminally ill, skip lines 17 through 25 and enter -0- on line 26.

17

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 . . . . . . . . . . . . . . . . . . . . .

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Yes

No

Yes

No

17

Caution: Do not use lines 18 through 26 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.
18
19

Enter the part of the amount on line 17 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) . .

18

20

Add lines 18 and 19 . . . . . . . . . . . . . . . . . .
Note: If you checked “Yes” on line 15 above, see Multiple Payees on
page 7 of the instructions before completing lines 21 through 25.

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20

21
22

Multiply $280 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) . . . . . .

21

Enter the larger of line 21 or line 22 . . . . . . . . . . . .
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.

23

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enter -0-. Also include this
line 21, enter “LTC” and the
. . . . . . . . . .

25

23
24

25
26

Per diem limitation. Subtract line 24 from line 23 . . . . . . .
Taxable payments. Subtract line 25 from line 20. If zero or less,
amount in the total on Form 1040, line 21. On the dotted line next to
amount . . . . . . . . . . . . . . . . . . . .

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Form 8853 (2009)