Form TC-97M Fillable Utah Medical Savings Account Reconciliation
(all forms fillable on Windows, Mac, Android tablets, and iPad using Adobe Reader XI)

1 3 Enter identifying information in boxes 1 2 and 3 210 N 1950 W Account Administrator Instructions Account administrator's address Account administrators must remit to the Tax Commission all penalty funds withheld from MSA non medical withdrawals Account administrator's name Federal ID number amount listed on this line by 10 (10%) This penalty amount must be withheld from the withdrawal and remitted Attach a copy of each individual account holder's TC 675M to the TC 97M and remit payments for penalties to the Tax before January 31 following the close of the taxable calendar year The account administrators must retain (COPY D) with below $4 000 Commission by January 31 following the close of the taxable calendar year Detach coupon below and return to the Utah State Tax Commission Do not send cash Do not staple check to this coupon Enter account administrator's fee charged to the account Enter amount contributed to the plan during the current calendar year Enter BEGINNING BALANCE in the account at the beginning of the calendar year Enter ENDING BALANCE in the account at the end of the calendar year (ADD lines 4 through 6 and SUBTRACT Enter interest earnings Enter non medical distributions not subject to penalties This includes withdrawals that occur when the balance Enter non medical distributions subject to penalties This includes withdrawals from the account for a purpose Enter qualified medical distributions Enter the 10% PENALTY amount withheld from the non medical distributions on line 9 This amount must be following the close of the taxable calendar year In addition account administrators must send to the Tax Commission a completed Statement of Withholding for Utah lines 7 through 10) Make check or money order payable to the Utah State Tax Commission Medical Saving Account (MSA) Medical Savings Account form TC 675M (COPY A) for each account holder on or before January 31 following the close of the account is greater than $4 000 dollars and the withdrawal does not result in the account balance dropping of the taxable calendar year other than medical expenses at any time the balance is below $4 000 To determine the penalty multiply the Records must be maintained by the account administrator supporting the amounts listed on the TC 675M for the current reported and remitted to the Tax Commission on form TC 97M Rev 12/96 SALT LAKE CITY UT 84134 Signature Date subject to penalty along with a Utah Medical Savings Account Reconciliation form TC 97M on or before January 31 TC 675M instructions: The account administrator must also provide a copy of form TC 675M (COPIES B and C) to the account holder on or their records to the Tax Commission Report the penalty on line 12 below Total MSA penalty amount remitted $ Total MSA penalty amount reported $ Total number of TC 675M's Use this form to reconcile and report Statement of Withholding For Utah Medical Savings Account TC 675M and pay Utah Medical Savings Account Reconciliation (MSA) TC 97M UTAH STATE TAX COMMISSION year end penalties for non medical withdrawals of MSA funds A reconciliation must be filed even if there are no penalties year filing and three previous year filings