Form 8889 - Health Savings Accounts (Hsas)
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28889
OMB No. 1545-0074
Health Savings Accounts (HSAs)
2015
Form
Information about Form 8889 and its separate instructions is available at
▶
Department of the Treasury
Attachment
Attach to Form 1040 or Form 1040NR.
53
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Internal Revenue Service
Sequence No.
Social security number of HSA
Name(s) shown on Form 1040 or Form 1040NR
beneficiary. If both spouses have
HSAs, see instructions
▶
Before you begin: Complete Form 8853, Archer MSAs and Long-Term Care Insurance Contracts, if required.
Part I
HSA Contributions and Deduction. See 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.
1
Check the box to indicate your coverage under a high-deductible health plan (HDHP) during
Family
Self-only
2015 (see instructions).
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2
HSA contributions you made for 2015 (or those made on your behalf), including those made
from January 1, 2016, through April 18, 2016, that were for 2015. Do not include employer
2
contributions, contributions through a cafeteria plan, or rollovers (see instructions) .
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3
If you were under age 55 at the end of 2015, and on the first day of every month during 2015,
you were, or were considered, an eligible individual with the same coverage, enter $3,350
($6,650 for family coverage). All others, see the instructions for the amount to enter .
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3
4
Enter the amount you and your employer contributed to your Archer MSAs for 2015 from Form
8853, lines 1 and 2. If you or your spouse had family coverage under an HDHP at any time
during 2015, also include any amount contributed to your spouse’s Archer MSAs .
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4
5
5
Subtract line 4 from line 3. If zero or less, enter -0- .
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6
Enter 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 2015, see the instructions for the amount to
6
enter
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7
If you were age 55 or older at the end of 2015, married, and you or your spouse had family
coverage under an HDHP at any time during 2015, enter your additional contribution amount
(see instructions)
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7
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8
Add lines 6 and 7 .
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9
Employer contributions made to your HSAs for 2015
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9
10
Qualified HSA funding distributions
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10
11
11
Add lines 9 and 10 .
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12
Subtract line 11 from line 8. If zero or less, enter -0- .
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12
13
HSA deduction. Enter the smaller of line 2 or line 12 here and on Form 1040, line 25, or Form
13
1040NR, line 25 .
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Caution: If line 2 is more than line 13, you may have to pay an additional tax (see instructions).
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.
14 a Total distributions you received in 2015 from all HSAs (see instructions) .
14a
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b Distributions included on line 14a that you rolled over to another HSA. Also include any excess
contributions (and the earnings on those excess contributions) included on line 14a that were
14b
withdrawn by the due date of your return (see instructions)
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c Subtract line 14b from line 14a .
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14c
15
Qualified medical expenses paid using HSA distributions (see instructions) .
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15
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 .
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16
17 a If any of the distributions included on line 16 meet any of the Exceptions to the Additional
20% Tax (see instructions), check here .
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b Additional 20% tax (see instructions). Enter 20% (.20) of the distributions included on line 16
that are subject to the additional 20% tax. Also include this amount in the total on Form 1040,
line 62, or Form 1040NR, line 60. Check box c on Form 1040, line 62, or box b on Form 1040NR,
line 60. Enter “HSA” and the amount on the line next to the box .
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17b
8889
For Paperwork Reduction Act Notice, see your tax return instructions.
Form
(2015)
Cat. No. 37621P
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