8889 Health Savings Accounts (HSAs)

Form

OMB No. 1545-0074

8889

Department of the Treasury
Internal Revenue Service

Health Savings Accounts (HSAs)
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Attach to Form 1040 or Form 1040NR.

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

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2008

Attachment
Sequence No.

See separate instructions.

Social security number of HSA
beneficiary. If both spouses have
HSAs, see page 2 of the instructions

53

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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.

1

Check the box to indicate your coverage under a high-deductible health plan (HDHP) during
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2008 (see page 4 of the instructions)

2

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)

3

4

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

5

Subtract line 4 from line 3. If zero or less, enter -0-

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 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

7

8
9
10
11
12
13

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).

Part II

Self-only

Family

2

3

4
5

6

7
8

11
12
13

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 Total distributions you received in 2008 from all HSAs (see page 6 of the instructions)

14a

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)

14b
14c
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
17a If any of the distributions included on line 16 meet any of the Exceptions to the Additional
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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

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17b
Form

8889

(2008)

Form 8889 (2008)

Part III

Page

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

Qualified HSA distribution

18

19

Last-month rule

19

20

Qualified HSA funding distribution

20

21

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

21

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

22

22

2

Form

8889

(2008)