OMB No. 1545-1743
Form
8851
Department of the Treasury
Internal Revenue Service
This report is for the period January 1 through:
a
b
Total number of
Archer MSAs (see
instructions)
©
Cat. No. 22932F
Summary of Archer MSAs
Form 8851 (Rev. 2-2007)
Trustee’s or custodian’s name
Number, street, and room or suite no.
City, state, and ZIP code
Employer identification number
©
For Paperwork Reduction Act Notice, see back of form.
Telephone number
c
Total number of previously
uninsured account holders
(see instructions)
©
( )
d
Total number of excludable
account holders (see
instructions)
©
Name of Account Holder
(Last name, first name, and middle initial)
Social Security Number
Check if
Previously
Uninsured
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
Check if
Excludable
Page 1 of
(Rev. February 2007)
June 30, 2005
June 30, 2006
Caution: A separate Form 8851 must be filed for each reporting period.
Page 2
Form 8851 (Rev. 2-2007)
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. Section 220(j) requires Archer MSA
trustees or custodians to report certain information.
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 time needed to complete and file this form will vary depending on
individual circumstances. The estimated average time is:
Recordkeeping 3 hr., 35 min.
Learning about the law or the form 6 min.
Preparing, copying, assembling, and
sending the form to the IRS 9 min.
If you have comments concerning the accuracy of these time estimates
or suggestions for making this form simpler, we would be happy to hear
from you. You can write to Internal Revenue Service, Tax Products
Coordinating Committee, SE:W:CAR:MP:T:T:SP, 1111 Constitution
Avenue, NW, IR-6406, Washington, D.C. 20224. Do not send the form to
this address. Instead, see Where To File above.
General Instructions
Purpose of Form
Use this form to report the total number of Archer MSAs you established,
the total number of previously uninsured account holders, the total
number of excludable account holders, and the names and social
security numbers (SSNs) of account holders. The report will be used to
furnish information about Archer MSAs to Congress and to determine
when the maximum number of Archer MSAs allowed by law (750,000,
excluding previously uninsured account holders) is reached.
Who Must File
File Form 8851 if you are the trustee or custodian of an Archer MSA. A
trustee or custodian may be a bank or similar financial institution, an
insurance company, or any other person approved by the IRS as a
trustee or custodian of an individual retirement arrangement (IRA).
When To File
Where To File
Send Form 8851 to:
How To File
If you are required to report more than 250 or more Archer MSAs, you
must file electronically. If you are required to report fewer than 250
Archer MSAs, you may file on paper, but you are strongly encouraged to
file electronically. See Announcement 2007-15 which is available in
Internal Revenue Bulletin 2007-8 at www.irs.gov/pub/irs-irbs/irb07-08.pdf.
For information on filing electronically, call toll-free at 1-866-455-7438. If
you file electronically, you must complete the trustee’s or custodian’s
information on Form 8851 (above line a) and transmit it to the IRS or fax
it to 304-264-5602.
Definitions
Previously uninsured account holder. An account holder is considered
to be previously uninsured if the account holder’s coverage under a high
deductible health plan did not begin before July 1, 1996, and
Specific Instructions
Box c. Enter the total number of previously uninsured Archer MSA
holders. See Previously uninsured account holder above.
Lines 1–20. Enter each Archer MSA holder’s name and SSN. If the
account holder is either previously uninsured or excludable, check the
appropriate box. Do not check both boxes for one account holder. Attach
additional sheets if necessary.
Box d. Enter the total number of excludable Archer MSA holders. See
Excludable account holder above. An Archer MSA holder cannot be both
previously uninsured and excludable. If you counted an Archer MSA
holder in box c, do not count that holder in box d.
High deductible health plan. A high deductible health plan for 2005 is a
health plan—
1. For self-only coverage that has an annual deductible between
$1,750 and $2,650 or, for family coverage, between $3,500 and $5,250.
2. The annual out-of-pocket expenses required to be paid under the
plan (other than for premiums) for covered benefits does not exceed—
a. $3,500 for self-only coverage and
b. $6,450 for family coverage.
Archer MSA. An Archer MSA is a trust created or organized in the United
States as a medical savings account exclusively for the purpose of
paying the qualified medical expenses of the account holder or the
account holder’s spouse or dependent, in conjunction with a high
deductible health plan.
1. Insurance, if substantially all the coverage provided under such
insurance relates to:
a. Liabilities incurred under workers’ compensation laws,
4. Coverage (whether through insurance or otherwise) for accidents,
disability, dental care, vision care, or long-term care.
3. Insurance paying a fixed amount per day (or other period) of
hospitalization.
c. Liabilities relating to ownership or use of property.
2. Insurance for a specified disease or illness.
b. Tort liabilities, or
Box b. Enter the total number of Archer MSAs you established during the
period covered by this Form 8851. This includes all Archer MSAs opened,
even those for previously uninsured or excludable account holders.
An account holder is considered previously uninsured even if the
account holder had any health plan coverage listed below.
Excludable account holder. A married account holder is considered an
excludable account holder if all three of the following apply.
If you simultaneously open an Archer MSA for a husband and an
Archer MSA for his wife and neither is considered previously uninsured,
treat either the husband or the wife, but not both, as an excludable
account holder.
For each reporting period, file a separate Form 8851 by March 20, 2007,
for Archer MSAs established:
Section references are to the Internal Revenue Code.
Do not report any Archer MSA established by a rollover from another
Archer MSA.
Do not report any Archer MSA established in the reporting period for
the prior year.
For self-only coverage, the account holder had no health plan
coverage at any time during the 6-month period before coverage under
the high deductible health plan began or
For family coverage, both the account holder and the account holder’s
spouse had no health plan coverage at any time during the 6-month
period before coverage under the high deductible health plan began.
1. The account holder is not considered previously uninsured.
2. The account holder opens an Archer MSA.
3. The account holder’s spouse has or had an Archer MSA and was
not considered previously uninsured.
IRS-Enterprise Computing Center—Martinsburg
Information Reporting Program
Attn: 8851 Coordinator
240 Murall Drive
Kearneysville, WV 25430
What’s New
The Tax Relief and Healthcare Act of 2006 requires trustees/custodians
to file Form 8851. See When To File below.
Do not include Medicare Advantage MSAs.
Do not report any Archer MSA that was established after June 30 of
the reporting period.
If an account holder has family coverage and either the account holder
or the account holder’s spouse was insured at any time during the
6-month period before coverage under the high deductible health plan
began or the coverage began before July 1, 1996, the account holder is
not considered previously uninsured.
For 2005, from January 1, 2005, through June 30, 2005, and
For 2006, from January 1, 2006, through June 30, 2006.
A high deductible health plan for 2006 is a health plan—
1. For self-only coverage that has an annual deductible between
$1,800 and $2,700 or, for family coverage, between $3,650 and $5,450.
2. The annual out-of-pocket expenses required to be paid under the
plan (other than for premiums) for covered benefits does not exceed—
a. $3,650 for self-only coverage and
b. $6,650 for family coverage.
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