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Indiana Indiana Individual Medical Savings Accounts
Form IN-MSA is obsolete, and is no longer supported by the Indiana Department of Revenue.
Extracted from PDF file 2019-indiana-form-in-msa.pdf, last modified September 2000Indiana Individual Medical Savings Accounts
PAYER'S name, street address, city state and zip code q CORRECTED (if checked) 1. Contributions 20___ Year 2. Medical withdrawals PAYER'S Federal identification number RECIPIENT'S social security number 3. Rollovers RECIPIENT'S name, street address (including apt. no.), city, state and zip code 4. Nonmedical withdrawals not subject to penalty 5. Interest - taxable Form IN-MSA SF 48244, Rev. 8/00 MSA q 6. Nonmedical withdrawals Attach this form to your Indiana income tax resubject to penalty turn if you are claiming Box 2 &/or Box 7 as a deduction on your Indi7. Interest - exempt ana income tax return. CORRECTED (if checked) 1. Contributions 2. Medical withdrawals RECIPIENT'S social security number 3. Rollovers RECIPIENT'S name, street address (including apt. no.), city, state and zip code 4. Nonmedical withdrawals not subject to penalty 5. Interest - taxable IN-MSA SF 48244, Rev. 8/00 PAYER'S name, street address, city state and zip code MSA 6. Nonmedical withdrawals Attach this form to your Indiana income tax resubject to penalty turn if you are claiming Box 2 &/or Box 7 as a deduction on your Indi7. Interest - exempt ana income tax return. q CORRECTED (if checked) 2. Medical withdrawals RECIPIENT'S social security number 3. Rollovers RECIPIENT'S name, street address (including apt. no.), city, state and zip code 4. Nonmedical withdrawals not subject to penalty 5. Interest - taxable IN-MSA SF 48244, Rev. 8/00 Indiana Individual Medical Savings Accounts 20___ Year Form Attach to state tax return if required Indiana Department of Revenue 1. Contributions PAYER'S Federal identification number Indiana Individual Medical Savings Accounts 20___ Year Form Attach to state tax return if required Indiana Department of Revenue PAYER'S name, street address, city state and zip code PAYER'S Federal identification number Indiana Individual Medical Savings Accounts MSA Attach to state tax return if required 6. Nonmedical withdrawals Attach this form to your Indiana income tax resubject to penalty turn if you are claiming Box 2 &/or Box 7 as a deduction on your Indi7. Interest - exempt ana income tax return. Indiana Department of Revenue Instructions for Plan Administrator (Payer) and Employee The plan administrator must report medical savings account information for each employee with respect to contributions, rollovers, interest income earned during the taxable year, distributions made to the account holder and amounts subject to penalty. From activity during the tax year: Enter total contributions in Box 1; Enter total withdrawals for medical reimbursements in Box 2; Enter rollovers in Box 3; Enter the nonmedical withdrawals made that are not subject to penalty in Box 4; Enter taxable interest from the account (that is also reported on Form 1099 INT) in Box 5; Enter the nonmedical withdrawals that are subject to penalty under IC 6-8-11-17(c) in Box 6; Enter in Box 7 the amount of interest (also included in the Box 5 total) that is exempt from Indiana adjusted gross income tax (that portion earned from employee's contribution). If there is a Box 6 entry the plan administrator must, by January 1 following the end of the tax year, mail: n a copy of this form; n Form MSA-3; and n the penalty amount withheld to: Indiana Department of Revenue P.O. Box 935 Indianapolis, IN 46206-0935 The employee must attach this form to the Indiana individual income tax return only when claiming an Indiana medical savings account deduction. Instructions for Plan Administrator (Payer) and Employee The plan administrator must report medical savings account information for each employee with respect to contributions, rollovers, interest income earned during the taxable year, distributions made to the account holder and amounts subject to penalty. From activity during the tax year: Enter total contributions in Box 1; Enter total withdrawals for medical reimbursements in Box 2; Enter rollovers in Box 3; Enter the nonmedical withdrawals made that are not subject to penalty in Box 4; Enter taxable interest from the account (that is also reported on Form 1099 INT) in Box 5; Enter the nonmedical withdrawals that are subject to penalty under IC 6-8-11-17(c) in Box 6; Enter in Box 7 the amount of interest (also included in the Box 5 total) that is exempt from Indiana adjusted gross income tax (that portion earned from employee's contribution). If there is a Box 6 entry the plan administrator must, by January 1 following the end of the tax year, mail: n a copy of this form; n Form MSA-3; and n the penalty amount withheld to: Indiana Department of Revenue P.O. Box 935 Indianapolis, IN 46206-0935 The employee must attach this form to the Indiana individual income tax return only when claiming an Indiana medical savings account deduction. Instructions for Plan Administrator (Payer) and Employee The plan administrator must report medical savings account information for each employee with respect to contributions, rollovers, interest income earned during the taxable year, distributions made to the account holder and amounts subject to penalty. From activity during the tax year: Enter total contributions in Box 1; Enter total withdrawals for medical reimbursements in Box 2; Enter rollovers in Box 3; Enter the nonmedical withdrawals made that are not subject to penalty in Box 4; Enter taxable interest from the account (that is also reported on Form 1099 INT) in Box 5; Enter the nonmedical withdrawals that are subject to penalty under IC 6-8-11-17(c) in Box 6; Enter in Box 7 the amount of interest (also included in the Box 5 total) that is exempt from Indiana adjusted gross income tax (that portion earned from employee's contribution). If there is a Box 6 entry the plan administrator must, by January 1 following the end of the tax year, mail: n a copy of this form; n Form MSA-3; and n the penalty amount withheld to: Indiana Department of Revenue P.O. Box 935 Indianapolis, IN 46206-0935 The employee must attach this form to the Indiana individual income tax return only when claiming an Indiana medical savings account deduction.
00-MSA
More about the Indiana Form IN-MSA Individual Income Tax
We last updated the Indiana Individual Medical Savings Accounts in May 2021, and the latest form we have available is for tax year 2019. This means that we don't yet have the updated form for the current tax year. Please check this page regularly, as we will post the updated form as soon as it is released by the Indiana Department of Revenue. You can print other Indiana tax forms here.
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TaxFormFinder has an additional 69 Indiana income tax forms that you may need, plus all federal income tax forms.
| Form Code | Form Name |
|---|---|
| Form ES-40 | Estimated Tax Payment Voucher |
| IT-40 Form | IT-40 Income Tax Form |
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| IT-40 Booklet | IT-40 Income Tax Instruction Booklet |
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View all 70 Indiana Income Tax Forms
Form Sources:
Indiana usually releases forms for the current tax year between January and April. We last updated Indiana Form IN-MSA from the Department of Revenue in May 2021.
About the Individual Income Tax
The IRS and most states collect a personal income tax, which is paid throughout the year via tax withholding or estimated income tax payments.
Most taxpayers are required to file a yearly income tax return in April to both the Internal Revenue Service and their state's revenue department, which will result in either a tax refund of excess withheld income or a tax payment if the withholding does not cover the taxpayer's entire liability. Every taxpayer's situation is different - please consult a CPA or licensed tax preparer to ensure that you are filing the correct tax forms!
Historical Past-Year Versions of Indiana Form IN-MSA
We have a total of nine past-year versions of Form IN-MSA in the TaxFormFinder archives, including for the previous tax year. Download past year versions of this tax form as PDFs here:
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