U.S. Individual Income Tax Return

2012

Department of the Treasury
Internal Revenue Service

Instructions for Form 8889
Health Savings Accounts (HSAs)
Section references are to the Internal Revenue
Code unless otherwise noted.

General Instructions
Future developments. For the latest
information about developments related
to Form 8889 and its instructions, such
as legislation enacted after they were
published, go to www.irs.gov/form8889.

What's New
Qualified HSA distribution.
Beginning in 2012 you can no longer
make a qualified HSA distribution. A
qualified HSA distribution is a one-time
distribution from a health flexible
spending arrangement (FSA) or health
reimbursement arrangement (HRA) that
is contributed by your employer directly
to your HSA. For more details, see
Qualified HSA distribution, later.

Purpose of Form
Use Form 8889 to:

Report health savings account (HSA)
contributions (including those made on
your behalf and employer contributions),
Figure your HSA deduction,
Report distributions from HSAs, and
Figure amounts you must include in
income and additional tax you may owe
if you fail to be an eligible individual.
Additional information. See Pub.
969, Health Savings Accounts and
Other Tax-Favored Health Plans, for
more details on HSAs.

Who Must File

You must file Form 8889 if any of the
following applies.
You (or someone on your behalf,
including your employer) made
contributions for 2012 to your HSA.
You received HSA distributions in
2012.
You must include certain amounts in
income because you failed to be an
eligible individual during the testing
period.
You acquired an interest in an HSA
because of the death of the account
beneficiary. See Death of Account
Beneficiary, later.

Sep 28, 2012

If you (or your spouse, if filing
jointly) received HSA
CAUTION
distributions in 2012, you must
file Form 8889 with a Form 1040 even if
you have no taxable income or any
other reason for filing Form 1040.

!

Definitions
Eligible Individual
To be eligible to have contributions
made to your HSA, you must be
covered under a high deductible health
plan (HDHP) and have no other health
coverage except permitted coverage. If
you are an eligible individual, anyone
can contribute to your HSA. However,
you cannot be enrolled in Medicare or
be claimed as a dependent on another
person's tax return. You must be, or be
considered, an eligible individual on the
first day of a month to take an HSA
deduction for that month (see
Last-month rule next).
Last-month rule. If you are an eligible
individual on the first day of the last
month of your tax year (December 1 for
most taxpayers), you are considered to
be an eligible individual for the entire
year.
Testing period. You must remain
an eligible individual during the testing
period. The testing period begins with
the last month of your tax year and ends
on the last day of the 12th month
following that month (for example,
December 1, 2012 – December 31,
2013). If you fail to remain an eligible
individual during this period, other than
because of death or becoming disabled,
you will have to include in income the
total contributions made that would not
have been made except for the
last-month rule. You include this amount
in income in the year in which you fail to
be an eligible individual. This amount is
also subject to a 10% additional tax.
(See Part III.)

Account Beneficiary
The account beneficiary is the individual
on whose behalf the HSA was
established.

Cat. No. 37971Y

HSA
Generally, an HSA is a health savings
account set up exclusively for paying
the qualified medical expenses of the
account beneficiary or the account
beneficiary's spouse or dependents.

Distributions From an HSA
Distributions from an HSA used
exclusively to pay qualified medical
expenses of the account beneficiary,
spouse, or dependents are excludable
from gross income. (See the line 15
instructions for information on medical
expenses of dependents not claimed on
your return.) You can receive
distributions from an HSA even if you
are not currently eligible to have
contributions made to the HSA.
However, any part of a distribution not
used to pay qualified medical expenses
is includible in gross income and is
subject to an additional 20% tax unless
an exception applies.

Qualified Medical Expenses
Generally, qualified medical expenses
for HSA purposes are unreimbursed
medical expenses that could otherwise
be deducted on Schedule A (Form
1040). See the Instructions for
Schedule A and Pub. 502, Medical and
Dental Expenses. Expenses incurred
before you establish your HSA are not
qualified medical expenses. If, under
the last-month rule, you are considered
to be an eligible individual for the entire
year for determining the contribution
amount, only those expenses incurred
after you actually establish your HSA
are qualified medical expenses.
Note. Non-prescription medicines
(other than insulin) are not qualified
medical expenses.
You cannot treat insurance premiums
as qualified medical expenses unless
the premiums are for:
1. Long-term care (LTC) insurance,
2. Health care continuation
coverage (such as coverage under
COBRA),
3. Health care coverage while
receiving unemployment compensation
under federal or state law, or

4. Medicare and other health care
coverage if you were 65 or older (other
than premiums for a Medicare
supplemental policy, such as Medigap).
Coverage under (2) and (3) can
be for your spouse or a
dependent meeting the
requirement. For (4), if you, the account
beneficiary, are under age 65, Medicare
premiums for your spouse or
dependents (who are age 65 or older)
generally are not qualified medical
expenses.

Liabilities under workers'
compensation laws, tort liabilities, or
liabilities arising from the ownership or
use of property;
A specific disease or illness; or
A fixed amount per day (or other
period) of hospitalization.
You can also have coverage (either
through insurance or otherwise) for
accidents, disability, dental care, vision
care, or long-term care.
For information on prescription drug
plans, see Pub. 969.

High Deductible Health Plan

Disabled

TIP

An HDHP is a health plan that meets the
following requirements.
Self-only
coverage
Minimum annual
deductible
Maximum annual
out-of-pocket
expenses*

$1,200

$6,050

Family
coverage
$2,400

$12,100

* This limit does not apply to deductibles and
expenses for out-of-network services if the plan
uses a network of providers. Instead, only
deductibles and out-of-pocket expenses (such
as copayments and other amounts, but not
premiums) for services within the network
should be used to figure whether the limit is
reached.

An HDHP can provide preventive
care and certain other benefits with no
deductible or a deductible below the
minimum annual deductible. For more
details, see Pub. 969. An HDHP does
not include a plan if substantially all of
the coverage is for accidents, disability,
dental care, vision care, or long-term
care. An HDHP also cannot be
insurance that you are permitted to have
in addition to an HDHP. See Other
Health Coverage next.

Other Health Coverage
If you have an HSA, you (and your
spouse, if you have family coverage)
generally cannot have any health
coverage other than an HDHP. But your
spouse can have health coverage other
than an HDHP if you are not covered by
that plan. If you have a health flexible
spending arrangement or health
reimbursement arrangement, see Pub.
969.
Exceptions. You can have additional
insurance that provides benefits only
for:

An individual generally is considered
disabled if he or she is unable to engage
in any substantial gainful activity due to
a physical or mental impairment which
can be expected to result in death or to
continue indefinitely.

Death of Account Beneficiary
If the account beneficiary's surviving
spouse is the designated beneficiary,
the HSA is treated as if the surviving
spouse were the account beneficiary.
The surviving spouse completes Form
8889 as though the HSA belonged to
him or her.
If the designated beneficiary is not
the account beneficiary's surviving
spouse, or there is no designated
beneficiary, the account ceases to be
an HSA as of the date of death. The
beneficiary completes Form 8889 as
follows.
Enter “Death of HSA account
beneficiary” across the top of Form
8889.
Enter the name(s) shown on your tax
return and your SSN in the spaces
provided at the top of the form and skip
Part I.
On line 14a, enter the fair market
value of the HSA as of the date of death.
On line 15, for a beneficiary other
than the estate, enter qualified medical
expenses incurred by the account
beneficiary before the date of death that
you paid within 1 year after the date of
death.
Complete the rest of Part II.
If the account beneficiary's estate is
the beneficiary, the value of the HSA as
of the date of death is included on the
account beneficiary's final income tax
return. Complete Form 8889 as
described above, except you should
complete Part I, if applicable.
The distribution is not subject to the
additional 20% tax. Report any earnings
-2-

on the account after the date of death as
income on your tax return.
Note. If, during the tax year, you are the
beneficiary of two or more HSAs or you
are a beneficiary of an HSA and you
have your own HSA, you must complete
a separate Form 8889 for each HSA.
Enter “statement” at the top of each
Form 8889 and complete the form as
instructed. Next, complete a controlling
Form 8889, combining the amounts
shown on each of the statement Forms
8889. Attach the statements to your tax
return after the controlling Form 8889.

Deemed Distributions From HSAs
The following situations result in
deemed distributions from your HSA.
You engaged in any transaction
prohibited by section 4975 with respect
to any of your HSAs, at any time in
2012. Your account ceases to be an
HSA as of January 1, 2012, and you
must include the fair market value of all
assets in the account as of January 1,
2012, on line 14a.
You used any portion of any of your
HSAs as security for a loan at any time
in 2012. You must include the fair
market value of the assets used as
security for the loan as income on
line 21 of Form 1040 or Form 1040NR.
Any deemed distribution will not be
treated as used to pay qualified medical
expenses. Generally, these distributions
are subject to the additional 20% tax.

Rollovers
A rollover is a tax-free distribution
(withdrawal) of assets from one HSA or
Archer MSA that is reinvested in
another HSA. Generally, you must
complete the rollover within 60 days
after you received the distribution. An
HSA can only receive one rollover
contribution during a 1-year period. See
Pub. 590, Individual Retirement
Arrangements (IRAs), for more details
and additional requirements regarding
rollovers.
Note. If you instruct the trustee of your
HSA to transfer funds directly to the
trustee of another HSA, the transfer is
not considered a rollover. There is no
limit on the number of these transfers.
Do not include the amount transferred in
income, deduct it as a contribution, or
include it as a distribution on line 14a.
Qualified HSA distribution. This is a
distribution made before January 1,
2012, from a health flexible spending
arrangement (FSA) or health
Form 8889 (2012)

reimbursement arrangement (HRA) that
is contributed by your employer directly
to your HSA. This is a one-time
distribution from any of these
arrangements. The distribution is
treated as a rollover contribution to the
HSA and is subject to the testing period
rules shown below. See Pub. 969 for
more information.
Testing period. You must remain
an eligible individual during the testing
period. The testing period begins with
the month in which the qualified HSA
distribution is contributed to the HSA
and ends on the last day of the 12th
month following that month. For
example, if the distribution is contributed
on June 14, 2011, the testing period
ends on June 30, 2012. If you fail to
remain an eligible individual during this
period, other than because of death or
becoming disabled, you will have to
include the qualified HSA distribution in
income in the year in which you fail to be
an eligible individual. This amount is
also subject to a 10% additional tax.
This distribution is included on line 19 of
this form. (See Part III.)

Specific Instructions
Name and social security number
(SSN). Enter your name(s) as shown
on your tax return and the SSN of the
HSA beneficiary. If married filing jointly
and both you and your spouse have
HSAs, complete a separate Form 8889
for each of you.

Part I—HSA Contributions
and Deductions

Use Part I to figure:
Your HSA deduction,
Any excess contributions you made
(or those made on your behalf), and
Any excess contributions made by an
employer (see Excess Employer
Contributions, later).

Figuring Your HSA Deduction

The maximum amount that can be
contributed to your HSA depends on the
type of HDHP coverage you have. If you
have self-only coverage, your maximum
contribution is $3,100. If you have family
coverage, your maximum contribution is
$6,250.
Note. If you are age 55 or older at the
end of your tax year, you can make an
additional contribution of $1,000.
Your maximum contribution is
reduced by any employer contributions
to your HSA, any contributions made to
Form 8889 (2012)

your Archer MSA, and any qualified
HSA funding distributions.
You can make deductible
contributions to your HSA even if your
employer made contributions. However,
if you (or someone on your behalf)
made contributions in addition to any
employer contributions and qualified
HSA funding distributions, you may
have to pay an additional tax. See
Excess Contributions You Make, later.
You cannot deduct any contributions
for any month in which you were
enrolled in Medicare. Also, you cannot
deduct contributions if you can be
claimed as a dependent on someone
else's 2012 tax return.

How To Complete Part I

Complete lines 1 through 13 as
instructed on the form. However, if you,
and your spouse if filing jointly, are both
eligible individuals and either of you
have an HDHP with family coverage,
you both are treated as having only the
family coverage plan. Disregard any
plans with self-only coverage.
Complete a separate Form 8889 for
each spouse. Combine the amounts on
line 13 of both Forms 8889 and enter
this amount on Form 1040, line 25; or
Form 1040NR, line 25. Be sure to attach
both Forms 8889 to your tax return.

Line 1

Line 3

When figuring the amount to enter on
line 3, apply the following rules.
1. Use the family coverage amount
if you or your spouse had an HDHP with
family coverage. Disregard any plan
with self-only coverage.
2. If the last-month rule (see
Last-month rule earlier) applies, you are
considered an eligible individual for the
entire year. You are treated as having
the same HDHP coverage for the entire
year as you had on the first day of the
last month of your tax year.
3. If you were, or were considered,
an eligible individual for the entire year
and you did not change your type of
coverage, enter $3,100 for a self-only
HDHP or $6,250 for a family HDHP on
line 3. (See (6) below.)
4. If you were, or were considered,
an eligible individual for the entire year
and you changed your type of coverage
during the year, enter on line 3 (see (6)
below) the greater of:
a. The limitation shown on the last
line of the Line 3 Limitation Chart and
Worksheet, later or
b. The maximum amount that can
be contributed based on the type of
HDHP coverage you had on the first day
of the last month of your tax year.
If you had family coverage on
the first day of the last month,
you do not need to use the
worksheet; enter $6,250 on line 3.

TIP

If you were covered, or considered
covered, by a self-only HDHP and a
family HDHP at different times during
the year, check the box for the plan that
was in effect for a longer period. If you
were covered by both a self-only HDHP
and a family HDHP at the same time,
you are treated as having family
coverage during that period. If, on the
first day of the last month of your tax
year, December 1 for most taxpayers,
you had family coverage, check the
“family” box.

Line 2

Include on line 2 only those amounts
you, or others on your behalf,
contributed to your HSA. Also, include
those contributions made from January
1, 2013, through April 15, 2013, that
were for 2012. Do not include employer
contributions (see line 9) or amounts
rolled over from another HSA or Archer
MSA. See Rollovers, earlier. Also, do
not include any qualified HSA funding
distributions (see line 10). Contributions
to an employee's account through a
cafeteria plan are treated as employer
contributions and are not included on
line 2.
-3-

5. If you were not an eligible
individual on the first day of the last
month of your tax year, use the Line 3
Limitation Chart and Worksheet, later to
determine the amount to enter on line 3.
(See (6) below.)
6. If, at the end of 2012, you were
age 55 or older and unmarried or
married with self-only HDHP coverage
for the entire year, you can increase the
amount determined in (3) or (4) by
$1,000 (the additional contribution
amount). For (5), the additional
contribution amount is taken into
account for each month you are an
eligible individual.
Note. If you are married and had family
coverage at any time during the year,
the additional contribution amount is
figured on line 7 and is not included on
line 3.
See Pub. 969 for more information.

Line 3 Limitation Chart and Worksheet

If you must complete the line 3
worksheet, and your eligibility
and coverage did not change
from one month to the next, enter the
same number you entered for the
previous month.

TIP

Line 6

Spouses who have separate HSAs and
had family coverage under an HDHP at
any time during 2012, use the following
rules to figure the amount on line 6.
If you are treated as having family
coverage for each month, divide the
amount on line 5 equally between you
and your spouse, unless you both agree
on a different allocation (such as
allocating nothing to one spouse). Enter
your allocable share on line 6.
Example. In 2012, you are an
eligible individual and have self-only
HDHP coverage. In March you marry
and as of April 1 you have family HDHP
coverage. Neither you nor your spouse
qualify for the additional contribution
amount. Your spouse has a separate
HSA and is an eligible individual from
April 1 to December 31, 2012. Because
you and your spouse are considered to
have family coverage on December 1,
your contribution limit is $6,250 (the
family coverage maximum). You and
your spouse can divide this amount in
any allocation to which you agree (such
as allocating nothing to one spouse).
If you are not treated as having family
coverage for each month, use the
following steps to determine the amount
to enter on line 6.

Before you begin: See the instructions for line 3, earlier.
Go through this chart for each month of 2012.
(Keep for your records)

Start Here
Were you enrolled in Medicare for the
month?

Yes

No
Were you an eligible individual (see
Eligible Individual, earlier) on the first
day of the month (see the line 3
instructions, earlier)?

No

Enter -0- on the line
below for the month.

Yes
What type of coverage did your HDHP provide on the first
day of the month?

Self-only coverage
Enter $3,100 on the line below for the
month. If you were age 55 or older at the
end of 2012, enter $4,100 for the month.

Family coverage
Enter $6,250 on the line below for the
month. If, at the end of 2012, you were
unmarried and age 55 or older, enter
$7,250 for the month.

Amount from
chart above

Month in 2012
January
February
March

Step 1. Refigure the contribution
limit that would have been entered on
line 5 if you had entered on line 3 the
total of the worksheet amounts only for
the months you were treated as having
family coverage. When refiguring line 5,
use the same amount you previously
entered on line 4.

April

Step 2. Divide the refigured
contribution limit from Step 1 equally
between you and your spouse, unless
you both agree on a different allocation
(such as allocating nothing to one
spouse).

September

Step 3. Subtract the part of the
contribution limit allocated to your
spouse in Step 2 from the amount
determined in Step 1.

Total for all months

May
June
July
August

October
November
December

Limitation. Divide the total by 12. Enter here and on line 3

-4-

Form 8889 (2012)

Step 4. Determine any other
contribution limits that apply for the tax
year and add that amount to the result in
Step 3. Enter the total on line 6.
Example. In 2012, you are an
eligible individual and have family
HDHP coverage. In March you divorce
and change your coverage as of April 1
to self-only. Neither you nor your
ex-spouse qualify for the additional
contribution amount. Your ex-spouse
continued to have family HDHP
coverage and was an eligible individual
for the entire year. The contribution limit
for the 3 months you both were
considered to have family coverage is
$1,562.50 ($6,250 × 3 ÷ 12). You and
your ex-spouse decide to divide the
family coverage contribution in the
following manner: 75% to your
ex-spouse and 25% to you. Your
contribution limit for 9 months of
self-only coverage is $2,325.00 ($3,100
× 9 ÷ 12). This amount is not divided
between you and your spouse.
Because you are covered under a
self-only policy on December 1, you will
show $3,100 on line 6 (the greater of
either (a) $2,715.62 ($1,562.50 family
coverage + $2,325.00 self-only
coverage – $1,171.88 spousal
allocation) or (b) the maximum amount
that can be contributed ($3,100 for
self-only coverage). Your ex-spouse
would show $6,250 on line 6 (the
greater of either (a) $5,859.37
($1,562.50 family coverage for the 3
months prior to the divorce + $4,687.50
family coverage maintained after the
divorce – $390.63 spousal allocation) or
(b) the maximum amount that can be
contributed ($6,250 for family
coverage).

2. You were not enrolled in
Medicare for the month.
Enter the result on line 7.

TIP

If items (1) and (2) apply to all
months during 2012, enter
$1,000 on line 7.

Additional Contribution Amount
Worksheet
1. $1,000 × number of months
eligible . . . . . . . . . . . . . . . . .
2. Divide line 1 by 12. Enter
here and on line 7 . . . . . . . .

Example. At the end of 2012, you
were age 55 and married. You had
family coverage under an HDHP from
January 1 through June 30, 2012 (6
months). You were not enrolled in
Medicare in 2012. You would enter an
additional contribution amount of $500
on line 7 ($1,000 × 6 ÷ 12).

Line 9
Employer Contributions

Line 7

Employer contributions (including
contributions through a cafeteria plan)
include any amount an employer
contributes to any HSA for you for 2012.
These contributions should be shown in
box 12 of Form W-2 with code W. If
either of the following apply, complete
the Employer Contribution Worksheet
below.
Employer contributions for 2011 are
included in the amount reported in
box 12 of Form W-2 with code W.
Employer contributions for 2012 are
made in 2013.
If your employer made excess
contributions, you may have to report
the excess as income. See Excess
Employer Contributions, later.

Additional Contribution Amount

Line 10

If, at the end of 2012, you were age 55
or older and married, use the Additional
Contribution Amount Worksheet, later, if
both of the following apply.
1. You or your spouse had family
coverage under an HDHP and were, or
were considered to be, an eligible
individual on the first day of the month.

Enter on line 10 any qualified HSA
funding distribution made during the
year. This is a distribution from your
traditional IRA or Roth IRA to your HSA
in a direct trustee-to-trustee transfer.
This distribution is not included in your
income, is not deductible, and reduces
the amount that can be contributed to
your HSA. This distribution cannot be

Employer Contribution Worksheet

made from an ongoing SEP IRA or
SIMPLE IRA. For this purpose, a SEP
IRA or SIMPLE IRA is ongoing if an
employer contribution is made for the
plan year ending with or within your tax
year in which the distribution would be
made.
The maximum amount that can be
excluded from income is based on your
age at the end of the year and your
HDHP coverage (self-only or family) at
the time of the distribution. You can
make only one qualified HSA funding
distribution during your lifetime.
However, if you make the distribution
during a month when you have self-only
HDHP coverage, you can make another
qualified HSA funding distribution in a
later month in that tax year if you
change to family HDHP coverage.
A qualified HSA funding distribution
made during your tax year reduces the
amount that can be contributed from
other sources (including employer
contributions) to your HSA. See the
discussions under Line 13 for the
treatment of excess contributions.
See Pub. 969 for more information.
Testing period. You must remain
an eligible individual during the testing
period. The testing period begins with
the month in which the qualified HSA
funding distribution is contributed to the
HSA and ends on the last day of the
12th month following that month. For
example, if the distribution is contributed
on June 14, 2012, the testing period
ends on June 30, 2013. If you fail to
remain an eligible individual during this
period, other than because of death or
becoming disabled, you will have to
include the qualified HSA funding
distribution in income in the year in
which you fail to be an eligible
individual. This amount is also subject to
a 10% additional tax. (See Part III.)

Line 13

If you or someone on your behalf (or
your employer) contributed more to your
HSA than is allowable, you may have to
pay an additional tax on the excess
contributions. Figure the excess
contributions using the instructions

Keep for Your Records

1. Enter the employer contributions reported in box 12 of Form W-2, with code W . . . . . . . . . . . . . . . . . . . . . . . . . .

1.

2. Enter employer contributions made in 2012 for tax year 2011 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

2.

3. Subtract line 2 from line 1 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

3.

4. Enter employer contributions made in 2013 for tax year 2012 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

4.

5. Employer contributions for 2012. Add lines 3 and 4. Enter here and on Form 8889, line 9 . . . . . . . . . . . . . . . .

5.

Form 8889 (2012)

-5-

below. See Form 5329, Additional
Taxes on Qualified Plans (Including
IRAs) and Other Tax-Favored Accounts,
to figure the additional tax.

Excess Contributions You Make
To figure your excess contributions
(including those made on your behalf),
subtract your deductible contributions
(line 13) from your actual contributions
(line 2). However, you can withdraw
some or all of your excess contributions
for 2012 and they will be treated as if
they had not been contributed if:
You make the withdrawal by the due
date, including extensions, of your 2012
tax return (but see the Note under
Excess Employer Contributions, later),
You do not claim a deduction for the
amount of the withdrawn contributions,
and
You also withdraw any income
earned on the withdrawn contributions
and include the earnings in “Other
income” on your tax return for the year
you withdraw the contributions and
earnings.

Excess Employer Contributions
Excess employer contributions are the
excess, if any, of your employer's
contributions over your limitation on
line 8. If you made a qualified HSA
funding distribution (line 10) during the
tax year, reduce your limitation (line 8)
by that distribution before you determine
whether you have excess employer
contributions. If the excess was not
included in income on Form W-2, you
must report it as “Other income” on your
tax return. However, you can withdraw
some or all of the excess employer
contributions for 2012 and they will be
treated as if they had not been
contributed if:
You make the withdrawal by the due
date, including extensions, of your 2012
tax return (but see the Note below),
You do not claim an exclusion from
income for the amount of the withdrawn
contributions, and
You also withdraw any income
earned on the withdrawn contributions
and include the earnings in “Other
income” on your tax return for the year
you withdraw the contributions and
earnings.
Note. If you timely filed your return
without withdrawing the excess
contributions, you can still make the
withdrawal no later than 6 months after
the due date of your tax return,
excluding extensions. If you do, file an
amended return with “Filed pursuant to

section 301.9100-2” written at the top.
Include an explanation of the
withdrawal. Make all necessary
changes on the amended return (for
example, if you reported the
contributions as excess contributions on
your original return, include an amended
Form 5329 reflecting that the withdrawn
contributions are no longer treated as
having been contributed).

Deducting an Excess Contribution
in a Later Year
You may be able to deduct excess
contributions for previous years that are
still in your HSA. The excess
contributions you can deduct in the
current year is the lesser of the following
two amounts.
Your maximum HSA contribution limit
for the year minus any amounts
contributed to your HSA for the year.
The total excess contributions in your
HSA at the beginning of the year.
Any excess contribution remaining at
the end of the tax year is subject to the
additional tax. See Form 5329.

Part II—HSA Distributions
Line 14a

Enter the total distributions you received
in 2012 from all HSAs. Your total
distributions include amounts paid with
a debit card that restricts payments to
health care and amounts withdrawn by
other individuals that you have
designated. These amounts should be
shown in box 1 of Form 1099-SA.

Line 14b

Include on line 14b any distributions you
received in 2012 that qualified as a
rollover contribution to another HSA.
See Rollovers, earlier. Also include any
excess contributions (and the earnings
on those excess contributions) included
on line 14a that were withdrawn by the
due date, including extensions, of your
return. See the instructions for line 13,
earlier.

Line 15
Only include on line 15
distributions from your HSA
CAUTION
that were used to pay you for
qualified medical expenses (see
Qualified Medical Expenses, earlier) not
reimbursed by insurance or other
coverage and that you incurred after the
HSA was established. Do not include
the distribution of an excess contribution
taken out after the due date, including

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extensions, of your return even if used
for qualified medical expenses.
In general, include on line 15
distributions from all HSAs in 2012 that
were used for the qualified medical
expenses (see Qualified Medical
Expenses, earlier) of:
1. Yourself and your spouse.
2. All dependents you claim on your
tax return.
3. Any person you could have
claimed as a dependent on your return
except that:
a. The person filed a joint return.
b. The person had gross income of
$3,800 or more.
c. You, or your spouse if filing
jointly, could be claimed as a dependent
on someone else's return.
For this purpose, a child of
parents that are divorced,
separated, or living apart for
the last 6 months of the calendar year is
treated as the dependent of both
parents whether or not the custodial
parent releases the claim to the child's
exemption.

TIP

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CAUTION

line 15.

You cannot take a deduction on
Schedule A (Form 1040) for
any amount you include on

Lines 17a and 17b
Additional 20% Tax
HSA distributions included in income
(line 16) are subject to an additional
20% tax unless one of the following
exceptions applies.

Exceptions to the Additional 20%
Tax
The additional 20% tax does not apply
to distributions made after the account
beneficiary—
Dies,
Becomes disabled (see Disabled,
earlier), or
Turns age 65.
If any of the exceptions apply to any
of the distributions included on line 16,
check the box on line 17a. Enter on
line 17b only 20% (.20) of any amount
included on line 16 that does not meet
any of the exceptions.
Example 1. You turned age 63 in 2012
and received a distribution from an HSA
that is included in income. Do not check
the box on line 17a because you (the
account beneficiary) did not meet the
age exception for the distribution. Enter
Form 8889 (2012)

20% of the amount from line 16 on
line 17b.
Example 2. You turned age 65 in
2012. You received distributions that are
included in income both before and after
you turned age 65. Check the box on
line 17a because the additional 20% tax
does not apply to the distributions made
after the date you turned age 65.
However, the additional 20% tax does
apply to the distributions made on or
before the date you turned age 65.
Enter on line 17b, 20% of the amount of
these distributions included in line 16.

Part III—Income and
Additional Tax for Failure
to Maintain HDHP
Coverage

Use Part III to figure any income and
additional tax that must be reported on

Form 8889 (2012)

Form 1040 or Form 1040NR for failure
to be an eligible individual during the
testing period for:
Last-month rule (see Last-month
rule, earlier),
A qualified HSA funding distribution
(see the instructions for line 10, earlier),
or
A qualified HSA distribution (see
Qualified HSA distribution, earlier).
See the discussions on the pages
indicated to determine the testing period
for each of these items. Include the
amount in income in the year in which
you fail to be an eligible individual.

Line 18

You can use the Line 3 Limitation Chart
and Worksheet in the Instructions for
Form 8889 for the year the contribution
was made to determine the contribution

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you could have made if the last-month
rule did not apply. Enter on line 18 the
excess of the amount contributed over
the redetermined amount. Examples of
this computation are in Pub. 969.

Line 19

Enter the total of any qualified HSA
funding distribution (see Line 10). Also
enter on line 19 the total of any qualified
HSA distribution (see Qualified HSA
distribution).