Archer MSAs and                                                      OMB No. 1545-0074 
Form 8853                              Long-Term Care Insurance Contracts
Department of the Treasury        Go to www.irs.gov/Form8853 for instructions and the latest information.                2023
                                                                                                                         Attachment   
Internal Revenue Service                       Attach to Form 1040, 1040-SR, or 1040-NR.                                 Sequence No. 39
Name(s) shown on return                                                               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    Total employer contributions to your Archer MSA(s) for 2023  .     . . . .  .        1
2    Archer MSA contributions you made for 2023, including those made in 2024 by the unextended due 
     date of your return that were for 2023. Don’t include rollovers. See instructions  . .   . .   . .    . .        2
3    Limitation from the Line 3 Limitation Chart and Worksheet in the instructions    .   .   . .   . .    . .        3
4    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.)  .    .   . . . .  .   .  . .      . . . . .  .    .   .   . .   . .    . .        4
5    Archer  MSA  deduction.      Enter  the smallest of  line  2,  3,  or  4  here.  Also  include  this  amount  on
     Schedule 1 (Form 1040), line 23     .   . . . .  .   .  . .      . . . . .  .    .   .   . .   . .    . .        5
     Caution: If line 2 is more than line 5, you may have to pay an additional tax. See instructions.
Part II Archer MSA Distributions
6a   Total distributions you and your spouse received in 2023 from all Archer MSAs (see instructions)  .     .        6a
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 unextended due date of your return. See instructions              6b
c    Subtract line 6b from line 6a     . .   . . . .  .   .  . .      . . . . .  .    .   .   . .   . .    . .        6c
7    Unreimbursed qualified medical expenses (see instructions)  .      . . . .  .    .   .   . .   . .    . .        7
8    Taxable Archer MSA distributions.Subtract line 7 from line 6c. If zero or less, enter -0-. Also include 
     this amount in the total on Schedule 1 (Form 1040), line 8e      . . . . .  .    .   .   . .   . .    . .        8
9 a  If any of the distributions included on line 8 meet any of the   Exceptions to the Additional 20% Tax 
     (see instructions), check here  .   .   . . . .  .   .  . .      . . . . .  .    .   .   . .   . .    .
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 Schedule     2 (Form 1040), 
     line 17e   .        .  . . . . .  . .   . . . .  .   .  . .      . . . . .  .    .   .   . .   . .    . .        9b
Section B.  Medicare Advantage MSA Distributions. If you are filing jointly and both you and your spouse received  
            distributions in 2023 from a Medicare Advantage MSA, complete a separate Section B for each spouse. See 
            instructions.
10   Total distributions you received in 2023 from all Medicare Advantage MSAs (see instructions)  .       . .        10
11   Unreimbursed qualified medical expenses (see instructions)  .      . . . .  .    .   .   . .   . .    . .        11
12   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 Schedule 1 (Form 1040), line 8e  . .   .   . .   . .    . .        12
13 a 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 2022. Also include this amount in the total on Schedule 2 (Form 1040), line 17f       . . .        13b
For Paperwork Reduction Act Notice, see your tax return instructions.                 Cat. No. 24091H                    Form 8853 (2023)

Form 8853 (2023)                                                                                    Attachment Sequence No. 39         Page 2 
Name of policyholder (as shown on return)                                                           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 Name of insured                                                          b      Social security number of insured
15  In 2023, 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? .          . . . .    . .    . . . .    . . . .    .  .   .      . .  . . .       . . .    .     Yes    No
16  Was the insured a terminally ill individual? .       .    . . . .    . . . .    .  .   .      . .  . . .       . . .    .     Yes    No
    Note: If “Yes” and the only payments you received in 2023 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  .            . . . . .    . .    . . . .    . . . .    .  .   .      . .  . . .       . .     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 Schedule 1
    (Form 1040), line 8e, or, for taxpayers filing Form 1040-NR, on Schedule NEC (Form 1040-NR), line 12.
18  Enter the part of the amount on line 17 that is from qualified LTC insurance contracts             . . .       . .     18
19  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  .        .  .   .      . .  . . .       . .     19
20  Add lines 18 and 19  .       .        . . . . .    . .    . . . .    . . . .    .  .   .      . .  . . .       . .     20
    Note: If  you  checked  “Yes”  on  line  15  above,  see      Multiple  Payees   in the
    instructions before completing lines 21 through 25.
21  Multiply $420 by the number of days in the LTC period  .        .    . . . .    .  .      21
22  Costs incurred for qualified LTC services provided for the insured during the
    LTC period (see instructions)           . . . .    . .    . . . .    . . . .    .  .      22
23  Enter the larger of line 21 or line 22  .     .    . .    . . . .    . . . .    .  .      23
24  Reimbursements for qualified LTC services provided for the insured during the
    LTC period  .       . . .    .        . . . . .    . .    . . . .    . . . .    .  .      24
    Caution:     If you received any reimbursements from LTC contracts issued       before August 1, 1996, see 
    instructions.
25  Per diem limitation. Subtract line 24 from line 23  .       . . .    . . . .    .  .   .      . .  . . .       . .     25
26  Taxable payments.       Subtract line 25 from line 20. If zero or less, enter -0-. Also include this amount in 
    the total on Schedule 1 (Form 1040), line 8e, or, for taxpayers filing Form 1040-NR, on Form 1040-NR, 
    Schedule NEC, line 12. For taxpayers filing Form 1040-NR, on Schedule NEC (Form 1040-NR), line 12, 
    enter “LTC” and the amount              . . . .    . .    . . . .    . . . .    .  .   .      . .  . . .       . .     26
                                                                                                                                Form 8853 (2023)