8959 Additional Medicare Tax

Form

8959

Department of the Treasury
Internal Revenue Service

Additional Medicare Tax

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OMB No. 1545-0074

Attach to Form 1040, 1040-SR, 1040-NR, 1040-PR, or 1040-SS.
to www.irs.gov/Form8959 for instructions and the latest information.

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Total Additional Medicare Tax

Add lines 7, 13, and 17. Also include this amount on Schedule 2 (Form 1040), line 11 (Form 1040-PR
or 1040-SS filers, see instructions), and go to Part V . . . . . . . . . . . . . . . . .

Part V
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Additional Medicare Tax on Railroad Retirement Tax Act (RRTA) Compensation

Railroad retirement (RRTA) compensation and tips from Form(s) W-2, box 14
(see instructions) . . . . . . . . . . . . . . . . . . . .
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Enter the following amount for your filing status:
Married filing jointly . . . . . . . . . . . . . . . $250,000
Married filing separately . . . . . . . . . . . . . . $125,000
Single, Head of household, or Qualifying widow(er) . . . . . $200,000
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Subtract line 15 from line 14. If zero or less, enter -0- . . . . . . . . . . . . . . . .
Additional Medicare Tax on railroad retirement (RRTA) compensation. Multiply line 16 by 0.9% (0.009).
Enter here and go to Part IV . . . . . . . . . . . . . . . . . . . . . . . . .

Part IV
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Additional Medicare Tax on Self-Employment Income

Self-employment income from Schedule SE (Form 1040), Part I, line 6. If you
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had a loss, enter -0- (Form 1040-PR or 1040-SS filers, see instructions.) . .
Enter the following amount for your filing status:
Married filing jointly . . . . . . . . . . . . . . . . $250,000
Married filing separately . . . . . . . . . . . . . . $125,000
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Single, Head of household, or Qualifying widow(er) . . . . . $200,000
Enter the amount from line 4 . . . . . . . . . . . . . . . .
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Subtract line 10 from line 9. If zero or less, enter -0- . . . . . . . . .
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Subtract line 11 from line 8. If zero or less, enter -0- . . . . . . . . . . . . . . . . .
Additional Medicare Tax on self-employment income. Multiply line 12 by 0.9% (0.009). Enter here and
go to Part III . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Part III
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Additional Medicare Tax on Medicare Wages

Medicare wages and tips from Form W-2, box 5. If you have more than one
Form W-2, enter the total of the amounts from box 5 . . . . . . . .
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Unreported tips from Form 4137, line 6 . . . . . . . . . . . . .
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Wages from Form 8919, line 6 . . . . . . . . . . . . . . . .
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Add lines 1 through 3 . . . . . . . . . . . . . . . . . . .
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Enter the following amount for your filing status:
Married filing jointly . . . . . . . . . . . . . . . $250,000
Married filing separately . . . . . . . . . . . . . . $125,000
Single, Head of household, or Qualifying widow(er) . . . . . $200,000
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Subtract line 5 from line 4. If zero or less, enter -0- . . . . . . . . . . . . . . . . .
Additional Medicare Tax on Medicare wages. Multiply line 6 by 0.9% (0.009). Enter here and go to
Part II . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Part II
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Attachment
Sequence No. 71
Your social security number

Name(s) shown on return

Part I

2021

If any line does not apply to you, leave it blank. See separate instructions.

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Withholding Reconciliation

Medicare tax withheld from Form W-2, box 6. If you have more than one Form
W-2, enter the total of the amounts from box 6 . . . . . . . . . .
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Enter the amount from line 1 . . . . . . . . . . . . . . . .
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Multiply line 20 by 1.45% (0.0145). This is your regular Medicare tax
withholding on Medicare wages . . . . . . . . . . . . . . .
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Subtract line 21 from line 19. If zero or less, enter -0-. This is your Additional Medicare Tax
withholding on Medicare wages . . . . . . . . . . . . . . . . . . . . . . .
Additional Medicare Tax withholding on railroad retirement (RRTA) compensation from Form W-2, box
14 (see instructions) . . . . . . . . . . . . . . . . . . . . . . . . . . .
Total Additional Medicare Tax withholding. Add lines 22 and 23. Also include this amount with
federal income tax withholding on Form 1040, 1040-SR, or 1040-NR, line 25c (Form 1040-PR or
1040-SS filers, see instructions) . . . . . . . . . . . . . . . . . . . . . . .

For Paperwork Reduction Act Notice, see your tax return instructions.

Cat. No. 59475X

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Form 8959 (2021)