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IRS8853.xsl
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<?xml version="1.0" encoding="UTF-8"?>
<xsl:stylesheet xmlns:xsl="http://www.w3.org/1999/XSL/Transform" version="1.0">
<xsl:include href="PopulateTemplate.xsl"/>
<xsl:include href="CommonPathRef.xsl"/>
<xsl:include href="AddHeader.xsl"/>
<xsl:include href="AddOnTable.xsl"/>
<xsl:include href="IRS8853Style.xsl"/>
<xsl:output method="html" indent="yes"/>
<xsl:strip-space elements="*"/>
<xsl:param name="Form8853Data" select="$RtnDoc/IRS8853"/>
<!-- ////////////////////////////////////////////////////////////// (Template: CreateBox) -->
<xsl:template name="CreateBox">
<xsl:param name="TargetNode"/>
<xsl:param name="StaticTextBefore"/>
<xsl:param name="AmountBoxStyle"/>
<xsl:param name="PopulateAsText"/>
<xsl:param name="Number"/>
<xsl:param name="NumberBoxStyle"/>
<xsl:param name="Width">29mm</xsl:param>
<xsl:param name="Height">5mm</xsl:param>
<div class="styLNAmountBox">
<xsl:attribute name="style">
width:<xsl:value-of select="$Width"/>;height:<xsl:value-of select="$Height"/>;
border-right-width:0px;float:right;text-align:right;padding-right:2px;font-size:6pt;
<xsl:choose><xsl:when test="$TargetNode"><xsl:choose><xsl:when test="$TargetNode/@referenceDocumentId">padding-top:3px;</xsl:when><xsl:otherwise>padding-top:6px;</xsl:otherwise></xsl:choose></xsl:when><xsl:otherwise>padding-top:2px;</xsl:otherwise></xsl:choose><xsl:if test="$AmountBoxStyle"><xsl:value-of select="$AmountBoxStyle"/></xsl:if></xsl:attribute>
<xsl:choose>
<xsl:when test="$TargetNode">
<xsl:value-of select="$StaticTextBefore"/>
<xsl:choose>
<xsl:when test="$PopulateAsText">
<xsl:call-template name="PopulateText">
<xsl:with-param name="TargetNode" select="$TargetNode"/>
</xsl:call-template>
</xsl:when>
<xsl:otherwise>
<xsl:call-template name="PopulateAmount">
<xsl:with-param name="TargetNode" select="$TargetNode"/>
</xsl:call-template>
</xsl:otherwise>
</xsl:choose>
<xsl:if test="$TargetNode/@referenceDocumentId">
<xsl:call-template name="SetFormLinkInline">
<xsl:with-param name="TargetNode" select="$TargetNode"/>
</xsl:call-template>
</xsl:if>
</xsl:when>
</xsl:choose>
</div>
<div class="styLNRightNumBox">
<xsl:attribute name="style">
float:right;
padding:3px 0px 0px 0px;
border-right-width:0px;
height:<xsl:value-of select="$Height"/>;
<xsl:if test="$NumberBoxStyle"><xsl:value-of select="$NumberBoxStyle"/></xsl:if></xsl:attribute>
<xsl:if test="$Number">
<xsl:value-of select="$Number"/>
</xsl:if>
</div>
</xsl:template>
<!-- /////////////////////////////////////////////////////////////////////////////////////////////////////// -->
<xsl:template match="/">
<html lang="EN-US">
<head>
<title>
<xsl:call-template name="FormTitle">
<xsl:with-param name="RootElement" select="local-name($Form8853Data)"/>
</xsl:call-template>
</title>
<!-- No Browser Caching -->
<meta http-equiv="Pragma" content="no-cache"/>
<meta http-equiv="Cache-Control" content="no-cache"/>
<meta http-equiv="Expires" content="0"/>
<!-- No Proxy Caching -->
<meta http-equiv="Cache-Control" content="private"/>
<!-- Define Character Set -->
<meta http-equiv="Content-Type" content="text/html; charset=ISO-8859-1"/>
<meta name="Description" content="IRS Form 8853"/>
<script language="JavaScript" src="{$ScriptPath}/FormDisplay.js" type="text/javascript"/>
<xsl:call-template name="InitJS"/>
<style type="text/css">
<xsl:if test="not($Print) or $Print=''">
<xsl:call-template name="IRS8853Style"/>
<xsl:call-template name="AddOnStyle"/>
</xsl:if>
</style>
<xsl:call-template name="GlobalStylesForm"/>
</head>
<body class="styBodyClass">
<form name="IRS8853">
<!-- Begin Header section 1 -->
<xsl:call-template name="DocumentHeader"/>
<div class="styBB" style="width:187mm;border-bottom-width:2px;">
<div class="styFNBox" style="width:31mm;height:22mm;border-right-width:2px;padding-top:.5mm;">
<div style="padding-top:1mm;">
Form<span class="styFormNumber"> 8853</span>
</div>
<!--General Dependency Push Pin-->
<xsl:call-template name="SetFormLinkInline">
<xsl:with-param name="TargetNode" select="$Form8853Data"/>
</xsl:call-template>
<xsl:call-template name="LinkToLeftoverDataTableInline">
<xsl:with-param name="Desc">Header Top Left - MSA Holder Death Indicator</xsl:with-param>
<xsl:with-param name="TargetNode" select="$Form8853Data/ArcherMSAAndMedcrAdvntgMSAGrp/MSAHolderDeathInd"/>
</xsl:call-template>
<xsl:call-template name="LinkToLeftoverDataTableInline">
<xsl:with-param name="Desc">Header Top Left - MSA Calculations Explanation Statement Code</xsl:with-param>
<xsl:with-param name="TargetNode" select="$Form8853Data/ArcherMSAAndMedcrAdvntgMSAGrp/MSACalculationsExplnStmtCd"/>
</xsl:call-template>
<br/>
<span class="styAgency">Department of the Treasury</span>
<br/>
<span class="styAgency">Internal Revenue Service (99)</span>
</div>
<div class="styFTBox" style="width:125mm;">
<!-- Main Title >>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>> -->
<div class="styMainTitle" style="height:8mm;">
Archer MSAs and<br/>
Long-Term Care Insurance Contracts
</div>
<div class="styFST" style="height:5mm;font-size:7pt;margin-left:2mm;text-align:center;">
<span style="text-align:center;font-weight:bold;">
<div style="width:100%;height:5mm;padding-left:0px;">
<div style="width:110mm;height:5mm;">
<br/>
<br/>
<img src="{$ImagePath}/8853_Bullet_Sm.gif" alt="SmallBullet"/>
Attach to Form 1040 or Form 1040NR.
<span style="width:6px;"/>
<img src="{$ImagePath}/8853_Bullet_Sm.gif" alt="SmallBullet"/>
See separate instructions.
</div>
</div>
</span>
</div>
</div>
<div class="styTYBox" style="width:30mm;border-left-width:2px;">
<div class="styOMB" style="height:2mm;font-size:7pt;">OMB No. 1545-0074</div>
<div class="styTY">20<span class="styTYColor">12</span>
</div>
<div style="margin-left:3mm;text-align:left;font-size:7pt;">
Attachment<br/>Sequence No.
<span class="styBoldText" style="font-size:9pt;">39</span>
</div>
</div>
</div>
<!-- End Header section 1 -->
<!-- Begin Names and Identifying number section -->
<div class="styBB" style="width:187mm;">
<div class="styNameBox" style="width:89mm;height:11mm;font-weight:normal;font-size:7pt;">
Name(s) shown on return<br/>
<xsl:call-template name="PopulateReturnHeaderFiler">
<xsl:with-param name="TargetNode">Name</xsl:with-param>
</xsl:call-template>
</div>
<div style="height:8mm;width:97mm;height:4mm;padding:0px 0px 0px 0px;font-size:7pt;" class="styEINBox">
<div class="styIRS8853LNDesc" style="width:65%;padding-left:3px;">
<span class="styNormalText">
Social security number of MSA<br/>
account holder. If both spouses<br/>
have MSAs, see instructions
<span style="width:3px;"/>
<img src="{$ImagePath}/8853_Bullet_Sm.gif" alt="SmallBullet"/>
</span>
</div>
<div class="styIRS8853LNDesc" style="width:35%;padding-left:0px;vertical-align:middle;">
<span style="font-weight:normal;text-align:center;width:100%;padding-top:3mm;">
<xsl:choose>
<xsl:when test="$Form8853Data/ArcherMSAAndMedcrAdvntgMSAGrp/MSAHolderSSN">
<xsl:call-template name="PopulateSSN">
<xsl:with-param name="TargetNode" select="$Form8853Data/ArcherMSAAndMedcrAdvntgMSAGrp/MSAHolderSSN"/>
<xsl:with-param name="BackupName">Form8853DataMSAHolderSSN</xsl:with-param>
</xsl:call-template>
</xsl:when>
<xsl:otherwise>
<xsl:call-template name="PopulateSSN">
<xsl:with-param name="TargetNode" select="$RtnHdrData/Filer/PrimarySSN"/>
<xsl:with-param name="BackupName">RtnHdrDataFilerPrimarySSN</xsl:with-param>
</xsl:call-template>
</xsl:otherwise>
</xsl:choose>
</span>
</div>
</div>
</div>
<!-- End Names and Identifying number section -->
<div class="styBB" style="width:187mm;">
<div class="styIRS8853LineItem" style="font-size:8pt;">
<b>Section A. Archer MSAs.</b> If you have only a Medicare Advantage MSA, skip Section A and complete Section B.
</div>
</div>
<!-- >>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>> -->
<!-- Begin Part I -->
<!-- <<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<< -->
<!-- Header -->
<div style="width:187mm;" class="styBB">
<!-- Content -->
<div class="styPartName" style="width:15mm;height:4mm;">Part I</div>
<div class="styPartDesc" style="padding-left:3mm;">
Archer MSA Contributions and Deductions. <span class="styNormalText">See instructions before completing this part. If<br/>
you are filing jointly and both you and your spouse have high deductible health plans with self-only coverage,<br/>
complete a separate Part I for each spouse.</span>
</div>
</div>
<!-- Body -->
<div class="styBB" style="width:187mm;">
<!-- (1) ////////////////////////////////////////////////////-->
<div class="styIRS8853LineItem">
<div class="styIRS8853LNLeftNumBox">1</div>
<div class="styIRS8853LNDesc" style="width:105mm;height:100%;padding:0px 0px 0px 0px;">
<div class="styIRS8853LNDesc" style="width:auto;height:100%;">
Total employer contributions to your Archer MSA(s) for 2012
</div>
<div class="styIRS8853LNDesc" style="width:auto;height:100%;text-align:right;float:right;padding:0px 3mm 0px 0px;">
<!--Dotted Line-->
<span class="styBoldText">
<span style="width:11px"/>.
<span style="width:11px"/>.
<span style="width:11px"/>.
<span style="width:11px"/>.
</span>
</div>
</div>
<div class="styIRS8853LNDesc" style="height:100%;width:75mm;float:right;padding:0px 0px 0px 0px;">
<div class="styIRS8853LNDesc" style="height:5mm;width:37mm;float:right;padding:0px 0px 0px 0px;">
<xsl:call-template name="CreateBox">
<xsl:with-param name="Height">100%</xsl:with-param>
<xsl:with-param name="AmountBoxStyle">border-width:0px 0px 0px 1px;padding:0px 0px 0px 0px;</xsl:with-param>
<xsl:with-param name="NumberBoxStyle">border-width:0px 0px 0px 1px;padding:0px 0px 0px 0px;background-color:lightgrey;</xsl:with-param>
</xsl:call-template>
</div>
<div class="styIRS8853LNDesc" style="height:auto;width:37mm;float:right;padding:0px 0px 0px 0px;">
<xsl:call-template name="CreateBox">
<xsl:with-param name="TargetNode" select="$Form8853Data/ArcherMSAAndMedcrAdvntgMSAGrp/ArcherMSAEmployerContriAmt"/>
<xsl:with-param name="Number">1</xsl:with-param>
</xsl:call-template>
</div>
</div>
</div>
<!-- (2) ////////////////////////////////////////////////////-->
<div class="styIRS8853LineItem">
<div class="styIRS8853LNLeftNumBox">2</div>
<div class="styIRS8853LNDesc" style="width:144mm;height:100%;padding:0px 0px 0px 0px;">
<div class="styIRS8853LNDesc" style="width:auto;height:100%;">
Archer MSA contributions you made for 2012, including those made from January 1, 2013,<br/>
through April 15, 2013, that were for 2012. Do not include rollovers (see instructions)
<span class="styBoldText">
<span style="width:11px"/>.
<span style="width:11px"/>.
<span style="width:11px"/>.
<span style="width:11px"/>.
<span style="width:11px"/>.
</span>
</div>
</div>
<xsl:call-template name="CreateBox">
<xsl:with-param name="Height">3.2mm</xsl:with-param>
<xsl:with-param name="AmountBoxStyle">border-width:0px 0px 0px 1px;padding:0px 0px 0px 0px;</xsl:with-param>
<xsl:with-param name="NumberBoxStyle">border-width:0px 0px 0px 1px;padding:0px 0px 0px 0px;background-color:lightgrey;</xsl:with-param>
</xsl:call-template>
<xsl:call-template name="CreateBox">
<xsl:with-param name="TargetNode" select="$Form8853Data/ArcherMSAAndMedcrAdvntgMSAGrp/ArcherMSAContributionAmt"/>
<xsl:with-param name="Number">2</xsl:with-param>
</xsl:call-template>
</div>
<!-- (3) ////////////////////////////////////////////////////-->
<div class="styIRS8853LineItem">
<div class="styIRS8853LNLeftNumBox">3</div>
<div class="styIRS8853LNDesc" style="width:144mm;height:100%;padding:0px 0px 0px 0px;">
<div class="styIRS8853LNDesc" style="width:auto;height:100%;">
Limitation from the Line 3 Limitation Chart and Worksheet in the instructions
</div>
<div class="styIRS8853LNDesc" style="width:auto;height:100%;text-align:right;float:right;padding:0px 3mm 0px 0px;">
<!--Dotted Line-->
<span class="styBoldText">
.
<span style="width:11px"/>.
<span style="width:11px"/>.
<span style="width:11px"/>.
<span style="width:11px"/>.
<span style="width:11px"/>.
<span style="width:11px"/>.
<span style="width:11px"/>.
</span>
</div>
</div>
<xsl:call-template name="CreateBox">
<xsl:with-param name="TargetNode" select="$Form8853Data/ArcherMSAAndMedcrAdvntgMSAGrp/ArcherMSAContriLimitationAmt"/>
<xsl:with-param name="Number">3</xsl:with-param>
</xsl:call-template>
</div>
<!-- (4) ////////////////////////////////////////////////////-->
<div class="styIRS8853LineItem">
<div class="styIRS8853LNLeftNumBox">4</div>
<div class="styIRS8853LNDesc" style="width:144mm;height:100%;padding:0px 0px 0px 0px;">
<div class="styIRS8853LNDesc" style="width:auto;height:100%;">
Compensation (see instructions) from the employer maintaining the high deductible<br/>
health plan. (If self-employed, enter your earned income from the trade or business under which<br/>
the high deductible health plan was established.)
<!--Dotted Line-->
<span class="styBoldText">
<span style="width:19px"/>.
<span style="width:11px"/>.
<span style="width:11px"/>.
<span style="width:11px"/>.
<span style="width:11px"/>.
<span style="width:11px"/>.
<span style="width:11px"/>.
<span style="width:11px"/>.
<span style="width:11px"/>.
<span style="width:11px"/>.
<span style="width:11px"/>.
<span style="width:11px"/>.
<span style="width:11px"/>.
<span style="width:11px"/>.
<span style="width:11px"/>.
<span style="width:11px"/>.
</span>
</div>
</div>
<xsl:call-template name="CreateBox">
<xsl:with-param name="Height">6mm</xsl:with-param>
<xsl:with-param name="AmountBoxStyle">border-width:0px 0px 0px 1px;padding:0px 0px 0px 0px;</xsl:with-param>
<xsl:with-param name="NumberBoxStyle">border-width:0px 0px 0px 1px;padding:0px 0px 0px 0px;</xsl:with-param>
</xsl:call-template>
<xsl:call-template name="CreateBox">
<xsl:with-param name="TargetNode" select="$Form8853Data/ArcherMSAAndMedcrAdvntgMSAGrp/HDHPEmployerCompensationAmt"/>
<xsl:with-param name="Number">4</xsl:with-param>
</xsl:call-template>
</div>
<!-- (5) ////////////////////////////////////////////////////-->
<div class="styIRS8853LineItem">
<div class="styIRS8853LNLeftNumBox">5</div>
<div class="styIRS8853LNDesc" style="width:144mm;height:100%;padding:0px 0px 0px 0px;">
<div class="styIRS8853LNDesc" style="width:auto;height:100%;">
<b>Archer MSA deduction.</b> Enter the <b>smallest</b> of line 2, 3, or 4 here. Also include this amount on<br/>
Form 1040, line 36, or Form 1040NR, line 35. On the dotted line next to Form 1040, line 36, or<br/>
Form 1040NR, line 35, enter “MSA” and the amount
<!--Dotted Line-->
<span class="styBoldText">
<span style="width:20px"/>.
<span style="width:11px"/>.
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<span style="width:11px"/>.
<span style="width:11px"/>.
</span>
</div>
</div>
<xsl:call-template name="CreateBox">
<xsl:with-param name="Height">6mm</xsl:with-param>
<xsl:with-param name="AmountBoxStyle">border-width:0px 0px 0px 1px;padding:0px 0px 0px 0px;</xsl:with-param>
<xsl:with-param name="NumberBoxStyle">border-width:0px 0px 0px 1px;padding:0px 0px 0px 0px;</xsl:with-param>
</xsl:call-template>
<xsl:call-template name="CreateBox">
<xsl:with-param name="TargetNode" select="$Form8853Data/ArcherMSAAndMedcrAdvntgMSAGrp/ArcherMSADeductionAmt"/>
<xsl:with-param name="Number">5</xsl:with-param>
</xsl:call-template>
</div>
<div class="styIRS8853LineItem">
<div class="styIRS8853LNLeftNumBox"/>
<div class="styIRS8853LNDesc" style="width:144mm;height:100%;padding:0px 0px 0px 0px;">
<div class="styIRS8853LNDesc" style="width:auto;height:100%;">
<b>Caution:</b>
<span class="styItalicText">If line 2 is more than line 5, you may have to pay an additional tax (see instructions).</span>
</div>
</div>
</div>
</div>
<!-- >>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>> -->
<!-- Begin Part II -->
<!-- <<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<< -->
<!-- Header -->
<div style="width:187mm;" class="styBB">
<!-- Content -->
<div class="styPartName" style="width:15mm;height:4mm;">Part II</div>
<div class="styPartDesc" style="padding-left:3mm;">
Archer MSA Distributions
</div>
</div>
<!-- Body -->
<div class="styBB" style="width:187mm;">
<!-- (6a) ////////////////////////////////////////////////////-->
<div class="styIRS8853LineItem">
<div class="styIRS8853LNLeftNumBox" style="padding-right:0px;">6a</div>
<div class="styIRS8853LNDesc" style="width:144mm;height:100%;padding:0px 0px 0px 0px;">
<div class="styIRS8853LNDesc" style="width:auto;height:100%;">
Total distributions you and your spouse received in 2012 from all Archer MSAs (see instructions)
<!--Dotted Line-->
<span class="styBoldText">
<span style="width:10px"/>.
<span style="width:11px"/>.
</span>
</div>
</div>
<xsl:call-template name="CreateBox">
<xsl:with-param name="TargetNode" select="$Form8853Data/ArcherMSAAndMedcrAdvntgMSAGrp/TotalArcherMSADistributionAmt"/>
<xsl:with-param name="Number">6a</xsl:with-param>
</xsl:call-template>
</div>
<!-- (6b) ////////////////////////////////////////////////////-->
<div class="styIRS8853LineItem">
<div class="styIRS8853LNLeftNumBox" style="padding-right:0px;">b</div>
<div class="styIRS8853LNDesc" style="width:144mm;height:100%;padding:0px 0px 0px 0px;">
<div class="styIRS8853LNDesc" style="width:auto;height:100%;">
Distributions included on line 6a that you rolled over to another Archer MSA or a health savings<br/>
account. Also include any excess contributions (and the earnings on those excess contributions)<br/>
included on line 6a that were withdrawn by the due date of your return (see instructions)
<!--Dotted Line-->
<span class="styBoldText">
<span style="width:10px"/>.
<span style="width:11px"/>.
<span style="width:11px"/>.
<span style="width:11px"/>.
<span style="width:11px"/>.
</span>
</div>
</div>
<xsl:call-template name="CreateBox">
<xsl:with-param name="Height">6mm</xsl:with-param>
<xsl:with-param name="AmountBoxStyle">border-width:0px 0px 0px 1px;padding:0px 0px 0px 0px;</xsl:with-param>
<xsl:with-param name="NumberBoxStyle">border-width:0px 0px 0px 1px;padding:0px 0px 0px 0px;</xsl:with-param>
</xsl:call-template>
<xsl:call-template name="CreateBox">
<xsl:with-param name="TargetNode" select="$Form8853Data/ArcherMSAAndMedcrAdvntgMSAGrp/ArcherMSADistriRollOverAmt"/>
<xsl:with-param name="Number">6b</xsl:with-param>
</xsl:call-template>
</div>
<!-- (6c) ////////////////////////////////////////////////////-->
<div class="styIRS8853LineItem">
<div class="styIRS8853LNLeftNumBox" style="padding-right:0px;">c</div>
<div class="styIRS8853LNDesc" style="width:144mm;height:100%;padding:0px 0px 0px 0px;">
<div class="styIRS8853LNDesc" style="width:auto;height:100%;">
Subtract line 6b from line 6a
</div>
<div class="styIRS8853LNDesc" style="width:auto;height:100%;text-align:right;float:right;padding:0px 3mm 0px 0px;">
<!--Dotted Line-->
<span class="styBoldText">
<span style="width:11px"/>.
<span style="width:11px"/>.
<span style="width:11px"/>.
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<span style="width:11px"/>.
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<span style="width:11px"/>.
</span>
</div>
</div>
<xsl:call-template name="CreateBox">
<xsl:with-param name="TargetNode" select="$Form8853Data/ArcherMSAAndMedcrAdvntgMSAGrp/ArcherMSANetDistributionAmt"/>
<xsl:with-param name="Number">6c</xsl:with-param>
</xsl:call-template>
</div>
<!-- (7) ////////////////////////////////////////////////////-->
<div class="styIRS8853LineItem">
<div class="styIRS8853LNLeftNumBox">7</div>
<div class="styIRS8853LNDesc" style="width:144mm;height:100%;padding:0px 0px 0px 0px;">
<div class="styIRS8853LNDesc" style="width:auto;height:100%;">
Unreimbursed qualified medical expenses (see instructions)
</div>
<div class="styIRS8853LNDesc" style="width:auto;height:100%;text-align:right;float:right;padding:0px 3mm 0px 0px;">
<!--Dotted Line-->
<span class="styBoldText">
.
<span style="width:11px"/>.
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<span style="width:11px"/>.
<span style="width:11px"/>.
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</span>
</div>
</div>
<xsl:call-template name="CreateBox">
<xsl:with-param name="TargetNode" select="$Form8853Data/ArcherMSAAndMedcrAdvntgMSAGrp/ArcherMSAUnreimbQualMedExpAmt"/>
<xsl:with-param name="Number">7</xsl:with-param>
</xsl:call-template>
</div>
<!-- (8) ////////////////////////////////////////////////////-->
<div class="styIRS8853LineItem">
<div class="styIRS8853LNLeftNumBox">8</div>
<div class="styIRS8853LNDesc" style="width:144mm;height:100%;padding:0px 0px 0px 0px;">
<div class="styIRS8853LNDesc" style="width:auto;height:100%;">
<b>Taxable Archer MSA distributions.</b> Subtract line 7 from line 6c. If zero or less, enter -0-. Also<br/>
include this amount in the total on Form 1040, line 21, or Form 1040NR, line 21. On the dotted<br/>
line next to line 21, enter “MSA” and the amount
<!--Dotted Line-->
<span class="styBoldText">
<span style="width:20px"/>.
<span style="width:11px"/>.
<span style="width:11px"/>.
<span style="width:11px"/>.
<span style="width:11px"/>.
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</span>
</div>
</div>
<xsl:call-template name="CreateBox">
<xsl:with-param name="Height">6mm</xsl:with-param>
<xsl:with-param name="AmountBoxStyle">border-width:0px 0px 0px 1px;padding:0px 0px 0px 0px;</xsl:with-param>
<xsl:with-param name="NumberBoxStyle">border-width:0px 0px 0px 1px;padding:0px 0px 0px 0px;</xsl:with-param>
</xsl:call-template>
<xsl:call-template name="CreateBox">
<xsl:with-param name="TargetNode" select="$Form8853Data/ArcherMSAAndMedcrAdvntgMSAGrp/TaxableArcherMSADistriAmt"/>
<xsl:with-param name="Number">8</xsl:with-param>
</xsl:call-template>
</div>
<!-- (9a) ////////////////////////////////////////////////////-->
<div class="styIRS8853LineItem">
<div class="styIRS8853LNLeftNumBox" style="padding-right:0px;">9a</div>
<div class="styIRS8853LNDesc" style="width:144mm;height:100%;padding:0px 0px 0px 0px;">
<div class="styIRS8853LNDesc" style="width:auto;height:100%;">
If any of the distributions included on line 8 meet any of the <b>Exceptions to the Additional</b>
<br/>
<b>20% Tax</b> (see instructions), check here
<!--Dotted Line-->
<span class="styBoldText">
<span style="width:13px"/>.
<span style="width:11px"/>.
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<span style="width:11px"/>.
<span style="width:11px"/>.
<span style="width:11px"/>.
<span style="width:6px"/>
</span>
<img src="{$ImagePath}/8853_Bullet_Sm.gif" alt="SmallBullet"/>
<span style="width:5px"/>
<label>
<xsl:call-template name="PopulateLabel">
<xsl:with-param name="TargetNode" select="$Form8853Data/ArcherMSAAndMedcrAdvntgMSAGrp/ArcherMSADistriMeetTaxExcInd"/>
<xsl:with-param name="BackupName">Form8853DataArcherMSADistriMeetTaxExcInd</xsl:with-param>
</xsl:call-template>
</label>
<input class="styCkbox" type="checkbox" style="width:4mm;">
<xsl:call-template name="PopulateCheckbox">
<xsl:with-param name="TargetNode" select="$Form8853Data/ArcherMSAAndMedcrAdvntgMSAGrp/ArcherMSADistriMeetTaxExcInd"/>
<xsl:with-param name="BackupName">Form8853DataArcherMSADistriMeetTaxExcInd</xsl:with-param>
</xsl:call-template>
</input>
</div>
</div>
<xsl:call-template name="CreateBox">
<xsl:with-param name="Height">3.2mm</xsl:with-param>
<xsl:with-param name="AmountBoxStyle">border-width:0px 0px 0px 1px;padding:0px 0px 0px 0px;</xsl:with-param>
<xsl:with-param name="NumberBoxStyle">border-width:0px 0px 0px 1px;padding:0px 0px 0px 0px;background-color:lightgrey;</xsl:with-param>
</xsl:call-template>
<xsl:call-template name="CreateBox">
<xsl:with-param name="AmountBoxStyle">border-width:0px 0px 0px 1px;padding:0px 0px 0px 0px;</xsl:with-param>
<xsl:with-param name="NumberBoxStyle">border-width:0px 0px 0px 1px;padding:0px 0px 0px 0px;background-color:lightgrey;</xsl:with-param>
</xsl:call-template>
</div>
<!-- (9b) ////////////////////////////////////////////////////-->
<div class="styIRS8853LineItem">
<div class="styIRS8853LNLeftNumBox" style="padding-right:0px;">b</div>
<div class="styIRS8853LNDesc" style="width:144mm;height:100%;padding:0px 0px 0px 0px;">
<div class="styIRS8853LNDesc" style="width:auto;height:100%;">
<b>Additional 20% tax</b> (see instructions). Enter 20% (.20) of the distributions included<br/>
on line 8 that are subject to the additional 20% tax. Also include this amount in the total on Form<br/>
1040, line 60, or Form 1040NR, line 59. On the dotted line next to Form 1040, line 60, or Form<br/>
1040NR, line 59, enter “MSA” and the amount
<!--Dotted Line-->
<span class="styBoldText">
<span style="width:10px"/>.
<span style="width:11px"/>.
<span style="width:11px"/>.
<span style="width:11px"/>.
<span style="width:11px"/>.
<span style="width:11px"/>.
<span style="width:11px"/>.
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<span style="width:11px"/>.
<span style="width:11px"/>.
<span style="width:11px"/>.
<span style="width:11px"/>.
<span style="width:11px"/>.
</span>
</div>
</div>
<xsl:call-template name="CreateBox">
<xsl:with-param name="Height">9mm</xsl:with-param>
<xsl:with-param name="AmountBoxStyle">border-width:0px 0px 0px 1px;padding:0px 0px 0px 0px;</xsl:with-param>
<xsl:with-param name="NumberBoxStyle">border-width:0px 0px 0px 1px;padding:0px 0px 0px 0px;background-color:lightgrey;</xsl:with-param>
</xsl:call-template>
<xsl:call-template name="CreateBox">
<xsl:with-param name="TargetNode" select="$Form8853Data/ArcherMSAAndMedcrAdvntgMSAGrp/ArcherMSAAddnlDistriTaxAmt"/>
<xsl:with-param name="Number">9b</xsl:with-param>
<xsl:with-param name="AmountBoxStyle">border-bottom-width:0px;</xsl:with-param>
<xsl:with-param name="NumberBoxStyle">border-bottom-width:0px;</xsl:with-param>
</xsl:call-template>
</div>
</div>
<!-- >>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>> -->
<!-- Begin SECTION B. -->
<!-- <<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<< -->
<!-- Header -->
<div style="width:187mm;" class="styBB">
<!-- Content -->
<div class="styIRS8853LNDesc" style="width:21mm;font-size:8pt;padding-left:0px;text-align:center;">
<b>Section B.</b>
</div>
<div class="styPartDesc" style="padding-left:3mm;width:166mm;">
Medicare Advantage MSA Distributions. <span class="styNormalText">If you are filing jointly and both you and your spouse received
distributions in 2012 from a Medicare Advantage MSA, complete a separate Section B for each spouse (see
instructions).</span>
</div>
</div>
<!-- Body -->
<div class="styTBB" style="width:187mm;">
<!-- (10) ////////////////////////////////////////////////////-->
<div class="styIRS8853LineItem">
<div class="styIRS8853LNLeftNumBox">10</div>
<div class="styIRS8853LNDesc" style="width:144mm;height:100%;padding:0px 0px 0px 0px;">
<div class="styIRS8853LNDesc" style="width:auto;height:100%;">
Total distributions you received in 2012 from all Medicare Advantage MSAs (see instructions)
</div>
<div class="styIRS8853LNDesc" style="width:auto;height:100%;text-align:right;float:right;padding:0px 3mm 0px 0px;">
<!--Dotted Line-->
<span class="styBoldText">
.
<span style="width:11px"/>.
<span style="width:11px"/>.
</span>
</div>
</div>
<xsl:call-template name="CreateBox">
<xsl:with-param name="TargetNode" select="$Form8853Data/ArcherMSAAndMedcrAdvntgMSAGrp/TotalMedicareMSADistriAmt"/>
<xsl:with-param name="Number">10</xsl:with-param>
</xsl:call-template>
</div>
<!-- (11) ////////////////////////////////////////////////////-->
<div class="styIRS8853LineItem">
<div class="styIRS8853LNLeftNumBox">11</div>
<div class="styIRS8853LNDesc" style="width:144mm;height:100%;padding:0px 0px 0px 0px;">
<div class="styIRS8853LNDesc" style="width:auto;height:100%;">
Unreimbursed qualified medical expenses (see instructions)
</div>
<div class="styIRS8853LNDesc" style="width:auto;height:100%;text-align:right;float:right;padding:0px 3mm 0px 0px;">
<!--Dotted Line-->
<span class="styBoldText">
.
<span style="width:11px"/>.
<span style="width:11px"/>.
<span style="width:11px"/>.
<span style="width:11px"/>.
<span style="width:11px"/>.
<span style="width:11px"/>.
<span style="width:11px"/>.
<span style="width:11px"/>.
<span style="width:11px"/>.
<span style="width:11px"/>.
<span style="width:11px"/>.
<span style="width:11px"/>.
</span>
</div>
</div>
<xsl:call-template name="CreateBox">
<xsl:with-param name="TargetNode" select="$Form8853Data/ArcherMSAAndMedcrAdvntgMSAGrp/MedicareMSAUnrmbQualMedExpAmt"/>
<xsl:with-param name="Number">11</xsl:with-param>
</xsl:call-template>
</div>
<!-- (12) ////////////////////////////////////////////////////-->
<div class="styIRS8853LineItem">
<div class="styIRS8853LNLeftNumBox">12</div>
<div class="styIRS8853LNDesc" style="width:144mm;height:100%;padding:0px 0px 0px 0px;">
<div class="styIRS8853LNDesc" style="width:auto;height:100%;">
<b>Taxable Medicare Advantage MSA distributions.</b> Subtract line 11 from line 10. If zero or less,<br/>
enter -0-. Also include this amount in the total on Form 1040, line 21, or Form 1040NR, line 21.<br/>
On the dotted line next to line 21, enter “Med MSA” and the amount
<!--Dotted Line-->
<span class="styBoldText">
<span style="width:10px"/>.
<span style="width:11px"/>.
<span style="width:11px"/>.
<span style="width:11px"/>.
<span style="width:11px"/>.
<span style="width:11px"/>.
<span style="width:11px"/>.
<span style="width:11px"/>.
<span style="width:11px"/>.
<span style="width:11px"/>.
<span style="width:11px"/>.
</span>
</div>
</div>
<xsl:call-template name="CreateBox">
<xsl:with-param name="Height">6mm</xsl:with-param>
<xsl:with-param name="AmountBoxStyle">border-width:0px 0px 0px 1px;padding:0px 0px 0px 0px;</xsl:with-param>
<xsl:with-param name="NumberBoxStyle">border-width:0px 0px 0px 1px;padding:0px 0px 0px 0px;</xsl:with-param>
</xsl:call-template>
<xsl:call-template name="CreateBox">
<xsl:with-param name="TargetNode" select="$Form8853Data/ArcherMSAAndMedcrAdvntgMSAGrp/TaxableMedicareMSADistriAmt"/>
<xsl:with-param name="Number">12</xsl:with-param>
</xsl:call-template>
</div>
<!-- (13a) ////////////////////////////////////////////////////-->
<div class="styIRS8853LineItem">
<div class="styIRS8853LNLeftNumBox" style="padding-right:0px;">13a</div>
<div class="styIRS8853LNDesc" style="width:144mm;height:100%;padding:0px 0px 0px 0px;">
<div class="styIRS8853LNDesc" style="width:auto;height:100%;">
If any of the distributions included on line 12 meet any of the <b>Exceptions to the Additional</b>
<br/>
<b>50% Tax</b> (see instructions), check here
<!--Dotted Line-->
<span class="styBoldText">
<span style="width:14px"/>.
<span style="width:11px"/>.
<span style="width:11px"/>.
<span style="width:11px"/>.
<span style="width:11px"/>.
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<span style="width:11px"/>.
<span style="width:11px"/>.
<span style="width:11px"/>.
<span style="width:11px"/>.
<span style="width:11px"/>.
<span style="width:6px"/>
</span>
<img src="{$ImagePath}/8853_Bullet_Sm.gif" alt="SmallBullet"/>
<span style="width:5px"/>
<label>
<xsl:call-template name="PopulateLabel">
<xsl:with-param name="TargetNode" select="$Form8853Data/ArcherMSAAndMedcrAdvntgMSAGrp/MedicareMSADistriMeetTaxExcInd"/>
<xsl:with-param name="BackupName">Form8853DataMedicareMSADistriMeetTaxExcInd</xsl:with-param>
</xsl:call-template>
</label>
<input class="styCkbox" type="checkbox" style="width:4mm;">
<xsl:call-template name="PopulateCheckbox">
<xsl:with-param name="TargetNode" select="$Form8853Data/ArcherMSAAndMedcrAdvntgMSAGrp/MedicareMSADistriMeetTaxExcInd"/>
<xsl:with-param name="BackupName">Form8853DataMedicareMSADistriMeetTaxExcInd</xsl:with-param>
</xsl:call-template>
</input>
</div>
</div>
<xsl:call-template name="CreateBox">
<xsl:with-param name="Height">3.2mm</xsl:with-param>
<xsl:with-param name="AmountBoxStyle">border-width:0px 0px 0px 1px;padding:0px 0px 0px 0px;</xsl:with-param>
<xsl:with-param name="NumberBoxStyle">border-width:0px 0px 0px 1px;padding:0px 0px 0px 0px;background-color:lightgrey;</xsl:with-param>
</xsl:call-template>
<xsl:call-template name="CreateBox">
<xsl:with-param name="AmountBoxStyle">border-width:0px 0px 0px 1px;padding:0px 0px 0px 0px;</xsl:with-param>
<xsl:with-param name="NumberBoxStyle">border-width:0px 0px 0px 1px;padding:0px 0px 0px 0px;background-color:lightgrey;</xsl:with-param>
</xsl:call-template>
</div>
<!-- (13b) ////////////////////////////////////////////////////-->
<div class="styIRS8853LineItem">
<div class="styIRS8853LNLeftNumBox" style="padding-right:0px;">b</div>
<div class="styIRS8853LNDesc" style="width:144mm;height:100%;padding:0px 0px 0px 0px;">
<div class="styIRS8853LNDesc" style="width:auto;height:100%;">
<b>Additional 50% tax</b> (see instructions). Enter 50% (.50) of the distributions included on line 12 <br/>
that are subject to the additional 50% tax. Also include this amount in the total on Form1040, line 60, <br/>
or Form 1040NR, line 59. On the dotted line next to Form 1040, line 60, or Form 1040NR, line 59, <br/>
enter “Med MSA” and the amount
<!--Dotted Line-->
<span class="styBoldText">
<span style="width:8px"/>.
<span style="width:11px"/>.
<span style="width:11px"/>.
<span style="width:11px"/>.
<span style="width:11px"/>.
<span style="width:11px"/>.
<span style="width:11px"/>.
<span style="width:11px"/>.
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<span style="width:11px"/>.
<span style="width:11px"/>.
<span style="width:11px"/>.
</span>
</div>
</div>
<xsl:call-template name="CreateBox">
<xsl:with-param name="Height">9mm</xsl:with-param>
<xsl:with-param name="AmountBoxStyle">border-width:0px 0px 0px 1px;padding:0px 0px 0px 0px;</xsl:with-param>
<xsl:with-param name="NumberBoxStyle">border-width:0px 0px 0px 1px;padding:0px 0px 0px 0px;background-color:lightgrey;</xsl:with-param>
</xsl:call-template>
<xsl:call-template name="CreateBox">
<xsl:with-param name="TargetNode" select="$Form8853Data/ArcherMSAAndMedcrAdvntgMSAGrp/MedicareMSAAddnlDistriTaxAmt"/>
<xsl:with-param name="Number">13b</xsl:with-param>
<xsl:with-param name="AmountBoxStyle">border-bottom-width:0px;</xsl:with-param>
<xsl:with-param name="NumberBoxStyle">border-bottom-width:0px;</xsl:with-param>
</xsl:call-template>
</div>
</div>
<!-- <<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<< -->
<!-- Page Break and Footer-->
<div class="pageEnd" style="width:187mm;padding-top:1mm;">
<div style="float:left;">
<span class="styBoldText">
For Paperwork Reduction Act Notice, see your tax return instructions.
</span>
</div>
<div style="float:right;">
<span style="width:50px;"/>
Form
<span class="styBoldText" style="font-size:8pt;">8853</span> (2012)
</div>
<div style="float:right;text-align:center;width:26mm;font-size:7pt;">
Cat. No. 24091H
</div>
</div>
<!-- END Page Break and Footer-->
<!-- BEGIN Page Header -->
<div class="styTBB" style="width:187mm;padding-top:.5mm;">
<div style="float:left;">
Form 8853 (2012)
</div>
<div style="float:right;">
Page <span style="font-weight:bold;font-size:8pt;">2</span>
</div>
<span style="float:right;width:20mm;"/>
<div style="float:right;text-align:center;width:40mm;font-size:7pt;">
Attachment Sequence No. <span class="styBoldText" style="font-size:8pt;">39</span>
</div>
</div>
<!-- END Page Header -->
<!-- <<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<< -->
<div class="styBB" style="width:187mm;">
<div class="styNameBox" style="width:89mm;height:8mm;font-weight:normal;font-size:7pt;">
Name of policyholder (as shown on Form 1040)<br/>
<xsl:call-template name="PopulateText">
<xsl:with-param name="TargetNode" select="$Form8853Data/SectCLTCInsuranceCntrctGrp/LTCInsurancePolicyHolderName"/>
</xsl:call-template>
</div>
<div style="height:6mm;width:97mm;height:4mm;padding:0px 0px 0px 0px;font-size:7pt;" class="styEINBox">
<div class="styIRS8853LNDesc" style="width:65%;padding-left:3px;">
<span class="styNormalText">
Social security number of<br/>
policyholder
<span style="width:3px;"/>
<img src="{$ImagePath}/8853_Bullet_Sm.gif" alt="SmallBullet"/>
</span>
</div>
<div class="styIRS8853LNDesc" style="width:35%;padding-left:0px;vertical-align:middle;">
<span style="font-weight:normal;text-align:center;width:100%;padding-top:3mm;">
<xsl:call-template name="PopulateSSN">
<xsl:with-param name="TargetNode" select="$Form8853Data/SectCLTCInsuranceCntrctGrp/LTCInsurancePolicyHolderSSN"/>
</xsl:call-template>
</span>
</div>
</div>
</div>
<!-- >>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>> -->
<!-- Begin SECTION C. -->
<!-- <<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<< -->
<!-- Header -->
<div style="width:187mm;" class="styBB">
<!-- Content -->
<div class="styIRS8853LNDesc" style="width:21mm;font-size:8pt;padding-left:0px;text-align:center;">
<b>Section C.</b>
</div>
<div class="styPartDesc" style="padding-left:3mm;width:166mm;">
Long-Term Care (LTC) Insurance Contracts. <span class="styNormalText">See</span> Filing Requirements for Section C <span class="styNormalText">in the <br/>
instructions before completing this section.</span>
</div>
</div>
<!-- Body -->
<div class="styTBB" style="width:187mm;">
<!-- /////////////////////////////////////////////////////////-->
<div class="styIRS8853LineItem" style="padding-top:3px;">
<div class="styIRS8853LNLeftNumBox"/>
<div class="styIRS8853LNDesc" style="width:181mm;height:100%;padding:0px 0px 0px 0px;">
<div class="styIRS8853LNDesc" style="width:auto;height:100%;">
<b>If more than one Section C is attached, check here</b>
</div>
<div class="styIRS8853LNDesc" style="width:auto;height:100%;text-align:right;float:right;padding:0px 3mm 0px 0px;">
<!--Dotted Line-->
<span class="styBoldText">
.
<span style="width:11px"/>.
<span style="width:11px"/>.
<span style="width:11px"/>.
<span style="width:11px"/>.
<span style="width:11px"/>.
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<span style="width:11px"/>.
<span style="width:11px"/>.
<span style="width:6px"/>
</span>
<img src="{$ImagePath}/8853_Bullet_Sm.gif" alt="SmallBullet"/>
<span style="width:5px"/>
<label>
<xsl:call-template name="PopulateLabel">
<xsl:with-param name="TargetNode" select="$Form8853Data/SectCLTCInsuranceCntrctGrp/Form8853LTCMultipleCopiesInd"/>
<xsl:with-param name="BackupName">Form8853DataForm8853LTCMultipleCopiesInd</xsl:with-param>
</xsl:call-template>
</label>
<input class="styCkbox" type="checkbox" style="width:4mm;">
<xsl:call-template name="PopulateCheckbox">
<xsl:with-param name="TargetNode" select="$Form8853Data/SectCLTCInsuranceCntrctGrp/Form8853LTCMultipleCopiesInd"/>
<xsl:with-param name="BackupName">Form8853DataForm8853LTCMultipleCopiesInd</xsl:with-param>
</xsl:call-template>
</input>
</div>
</div>
</div>
<!-- (14a-b) ////////////////////////////////////////////////////-->
<div class="styIRS8853LineItem">
<div class="styIRS8853LNLeftNumBox" style="padding-right:0px;">14a</div>
<div class="styIRS8853LNDesc" style="width:181mm;height:100%;padding:0px 0px 0px 0px;">
<div class="styIRS8853LNDesc" style="width:17%;height:100%;">
Name of insured
<span style="width:5px"/>
<img src="{$ImagePath}/8853_Bullet_Sm.gif" alt="SmallBullet"/>
</div>
<div class="styIRS8853LNDesc" style="width:36%;height:100%;border-color:black;border-style:dotted;border-bottom-width:1px;">
<xsl:call-template name="PopulateText">
<xsl:with-param name="TargetNode" select="$Form8853Data/SectCLTCInsuranceCntrctGrp/LTCInsuredName"/>
</xsl:call-template>
<xsl:if test="$Form8853Data/SectCLTCInsuranceCntrctGrp/LTCInsuredNameControl">
<span style="width:5px;"/>
<xsl:call-template name="LinkToLeftoverDataTableInline">
<xsl:with-param name="Desc">LTC Insured Name Control</xsl:with-param>
<xsl:with-param name="TargetNode" select="$Form8853Data/SectCLTCInsuranceCntrctGrp/LTCInsuredNameControl"/>
</xsl:call-template>
</xsl:if>
</div>
<div class="styIRS8853LNDesc" style="width:31%;height:100%;">
<b>b</b>
<span style="width:5px;"/>Social security number of insured