Extracted Text
Highlighting: “"Smart Worksheet"”
Self-Only Coverage Plan Smart Worksheet
A If questions 1 and 2 in the Employer Contributions Smart Worksheet are not checked "yes",
answer the following question:
1 Did the make an MSA contribution related to
a high deductible health plan with self-only coverage
which was in effect at the same time as this plan? Yes No
EFTA01220515