Free 2008 Form 8889 - Federal

Form

8889

OMB No. 1545-0074

Health Savings Accounts (HSAs)
Attach to Form 1040 or Form 1040NR. See separate instructions.
Social security number of HSA beneficiary. If both spouses have HSAs, see page 2 of the instructions

Department of the Treasury Internal Revenue Service

Attachment Sequence No.

2008
53

Name(s) shown on Form 1040 or Form 1040NR

Before you begin: Complete Form 8853, Archer MSAs and Long-Term Care Insurance Contracts, if required. Part I HSA Contributions and Deduction. See page 3 of the instructions before completing this part. If you are filing jointly and both you and your spouse each have separate HSAs, complete a separate Part I for each spouse.
Self-only Family

1 2

Check the box to indicate your coverage under a high-deductible health plan (HDHP) during 2008 (see page 4 of the instructions) HSA contributions you made for 2008 (or those made on your behalf), including direct deposits of economic stimulus payments and those made from January 1, 2009, through April 15, 2009, that were for 2008. Do not include employer contributions, contributions through a cafeteria plan, or rollovers (see page 4 of the instructions) If you were under age 55 at the end of 2008, and on the first day of every month during 2008, you were, or were considered, an eligible individual with the same coverage, enter $2,900 ($5,800 for family coverage). All others, see page 4 of the instructions for the amount to enter Enter the amount you and your employer contributed to your Archer MSAs for 2008 from Form 8853, lines 3 and 4. If you or your spouse had family coverage under an HDHP at any time during 2008, also include any amount contributed to your spouse's Archer MSAs Subtract line 4 from line 3. If zero or less, enter -0Enter the amount from line 5. But if you and your spouse each have separate HSAs and had family coverage under an HDHP at any time during 2008, see the instructions on page 4 for the amount to enter If you were age 55 or older at the end of 2008, married, and you or your spouse had family coverage under an HDHP at any time during 2008, enter your additional contribution amount (see page 5 of the instructions) Add lines 6 and 7 9 Employer contributions made to your HSAs for 2008 10 Qualified HSA funding distributions Add lines 9 and 10 Subtract line 11 from line 8. If zero or less, enter -0HSA deduction. Enter the smaller of line 2 or line 12 here and on Form 1040, line 25, or Form 1040NR, line 25 Caution: If line 2 is more than line 13, you may have to pay an additional tax (see page 5 of the instructions).

2

3

3

4

5 6

4 5

6

7

8 9 10 11 12 13

7 8

11 12 13

Part II

HSA Distributions. If you are filing jointly and both you and your spouse each have separate HSAs, complete a separate Part II for each spouse.
14a

14a Total distributions you received in 2008 from all HSAs (see page 6 of the instructions) b Distributions included on line 14a that you rolled over to another HSA. Also include any portion of a direct deposit of an economic stimulus payment and excess contributions (and the earnings on those excess contributions) included on line 14a that were withdrawn by the due date of your return (see page 6 of the instructions) c Subtract line 14b from line 14a 15 Unreimbursed qualified medical expenses (see page 6 of the instructions) 16 Taxable HSA distributions. Subtract line 15 from line 14c. If zero or less, enter -0-. Also, include this amount in the total on Form 1040, line 21, or Form 1040NR, line 21. On the dotted line next to line 21, enter "HSA" and the amount 17a If any of the distributions included on line 16 meet any of the Exceptions to the Additional 10% Tax (see page 6 of the instructions), check here b Additional 10% tax (see page 6 of the instructions). Enter 10% (.10) of the distributions included on line 16 that are subject to the additional 10% tax. Also include this amount in the total on Form 1040, line 61, or Form 1040NR, line 57. On the dotted line next to Form 1040, line 61, or Form 1040NR, line 57, enter "HSA" and the amount
For Paperwork Reduction Act Notice, see page 5 of the instructions.
Cat. No. 37621P

14b 14c 15

16

17b
Form

8889

(2008)

Form 8889 (2008)

Page

2

Part III

Income and Additional Tax for Failure To Maintain HDHP Coverage. See page 6 of the instructions before completing this part. If you are filing jointly and both you and your spouse each have separate HSAs, complete a separate Part III for each spouse.
18 19 20

18 19 20 21

Qualified HSA distribution Last-month rule Qualified HSA funding distribution Total income. Add lines 18, 19, and 20. Include this amount on Form 1040, line 21, or Form 1040NR, line 21. On the dotted line next to Form 1040, line 21, or Form 1040NR, line 21, enter "HSA" and the amount Additional tax. Multiply line 21 by 10% (.10). Include this amount in the total on Form 1040, line 61, or Form 1040NR, line 57. On the dotted line next to Form 1040, line 61, or Form 1040NR, line 57, enter "HDHP" and the amount

21

22

22
Form

8889

(2008)