Federal Free Printable 2016 Form 8853 for 2017 Federal Archer MSAs and Long-Term Care Insurance Contracts

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Archer MSAs and Long-Term Care Insurance Contracts
2016 Form 8853

Form 8853 Department of the Treasury Internal Revenue Service (99) Archer MSAs and Long-Term Care Insurance Contracts ▶ OMB No. 1545-0074 Information about Form 8853 and its separate instructions is available at www.irs.gov/form8853. ▶ Attach to Form 1040 or Form 1040NR. Name(s) shown on return 2016 Attachment Sequence No. 39 Social security number of MSA account holder. If both spouses have MSAs, see 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 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 Total employer contributions to your Archer MSA(s) for 2016 . . . . 1 Archer MSA contributions you made for 2016, including those made from January 1, 2017, through April 18, 2017, that were for 2016. Don't include rollovers (see instructions) . . . . . 3 4 Limitation from the Line 3 Limitation Chart and Worksheet in the instructions . . . . . . . Compensation (see 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.) . . . . . . . . . . . . . . . . . . . 5 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 35. On the dotted line next to Form 1040, line 36, or Form 1040NR, line 35, enter “MSA” and the amount . . . . . . . . . . . . . . . Caution: If line 2 is more than line 5, you may have to pay an additional tax (see instructions). 2 3 4 . 5 6a Total distributions you and your spouse received in 2016 from all Archer MSAs (see 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 Also include any excess contributions (and the earnings on those excess contributions) included on line 6a that were withdrawn by the due date of your return (see instructions) . . . . 6a Part II c 7 8 9a Archer MSA Distributions Subtract line 6b from line 6a . . . . . . . . . . . . . . . . . . . . . . Unreimbursed qualified medical expenses (see 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 20% Tax (see instructions), check here . . . . . . . . . . . . . . . . . . ▶ . . 6b 6c 7 . 8 b Additional 20% tax (see instructions). Enter 20% (0.20) of the distributions included on line 8 that are subject to the additional 20% tax. Also include this amount in the total on Form 1040, line 62, or Form 1040NR, line 60. Check box c on Form 1040, line 62, or box b on Form 1040NR, line 60. Enter “MSA” and the amount on the line next to the box . . . . . . . . . . . . . . 9b Section B. Medicare Advantage MSA Distributions. If you are filing jointly and both you and your spouse received distributions in 2016 from a Medicare Advantage MSA, complete a separate Section B for each spouse (see instructions). 10 11 12 13a Total distributions you received in 2016 from all Medicare Advantage MSAs (see instructions) . . Unreimbursed qualified medical expenses (see 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 instructions), check here . . . . . . . . . . . . . . . . . . ▶ b Additional 50% tax. Enter 50% (0.50) of the distributions included on line 12 that are subject to the additional 50% tax. See instructions for the amount to enter if you had a Medicare Advantage MSA at the end of 2015. Also include this amount in the total on Form 1040, line 62, or Form 1040NR, line 60. Check box c on Form 1040, line 62, or box b on Form 1040NR, line 60. Enter “Med MSA” and the amount on the line next to the box . . . . . . . . . . . . . . For Paperwork Reduction Act Notice, see your tax return instructions. Cat. No. 24091H 10 11 12 13b Form 8853 (2016) Form 8853 (2016) 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 in the instructions before completing this section. If more than one Section C is attached, check here . . . . . . . . . . . . . . . . . . 14a 15 Name of insured ▶ b Social security number of insured ▶ In 2016, 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 2016 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 . . . . . . . . . . . . . . . . . . . . . . . . Yes Yes . ▶ No No 17 Caution: Don't use lines 18 through 26 to figure the taxable amount of benefits paid under an LTC insurance contract that isn't a qualified LTC insurance contract. Instead, if the benefits aren't excludable from your income (for example, if the benefits aren't 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. Don't include any amounts you received because the insured was terminally ill (see instructions) . . . . . . 20 Add lines 18 and 19 . . . . . . . . . . . . . . . . . Note: If you checked “Yes” on line 15 above, see Multiple Payees in the instructions before completing lines 21 through 25. 21 22 Multiply $340 by the number of days in the LTC period . . . . . Costs incurred for qualified LTC services provided for the insured during the LTC period (see instructions) . . . . . . . . . . 23 24 25 26 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 instructions. . . . 21 . . 22 23 . 24 . . . . . . . 18 . 19 20 . Per diem limitation. Subtract line 24 from line 23 . . . . . . . . . . . . . . . . . Taxable payments. Subtract line 25 from line 20. 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 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25 26 Form 8853 (2016)
Extracted from PDF file 2016-federal-form-8853.pdf, last modified November 2016

More about the Federal Form 8853 Other TY 2016

We last updated the Archer MSAs and Long-Term Care Insurance Contracts in May 2017, so this is the latest version of Form 8853, fully updated for tax year 2016. You can download or print current or past-year PDFs of Form 8853 directly from TaxFormFinder. You can print other Federal tax forms here.

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Form Sources:

The Internal Revenue Service usually releases income tax forms for the current tax year between October and January, although changes to some forms can come even later. We last updated Federal Form 8853 from the Internal Revenue Service in May 2017.

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Historical Past-Year Versions of Federal Form 8853

We have a total of six past-year versions of Form 8853 in the TaxFormFinder archives, including for the previous tax year. Download past year versions of this tax form as PDFs here:


2016 Form 8853

2016 Form 8853

Archer MSAs and Long-Term Care Insurance Contracts 2015 Form 8853

2015 Form 8853

Archer MSAs and Long-Term Care Insurance Contracts 2014 Form 8853

2014 Form 8853

Archer MSAs and Long-Term Care Insurance Contracts 2013 Form 8853

2013 Form 8853

Archer MSAs and Long-Term Care Insurance Contracts 2012 Form 8853

2012 Form 8853

Archer MSAs and Long-Term Care Insurance Contracts 2011 Form 8853

2011 Form 8853


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