Instructions For Form 8889 - Health Savings Accounts - 2010 Page 3
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6Specific Instructions
Line 3 Limitation Chart and Worksheet
Before you begin: See the instructions for line 3 on page 4.
Name and social security number
Go through this chart for each month of 2010.
(SSN). Enter your name(s) as shown
on your tax return and the SSN of the
(Keep for your records)
HSA beneficiary. If married filing jointly
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and both you and your spouse have
HSAs, complete a separate Form 8889
Were you enrolled in Medicare for the
for each of you.
Yes
month?
Part I—HSA
No
Contributions and
Deductions
Were you an eligible individual (see
Use Part I to figure:
page 1 of the instructions) on the first
Enter -0- on the line
•
No
Your HSA deduction,
day of the month (see the line 3
below for the month.
•
Any excess contributions you made
instructions on page 4)?
(or those made on your behalf), and
•
Any excess contributions made by an
Yes
employer (see Excess Employer
Contributions beginning on page 5).
Figuring Your HSA
What type of coverage did your HDHP provide on the first
Deduction
day of the month?
The maximum amount that can be
contributed to your HSA depends on
the type of HDHP coverage you have. If
Self-only coverage
Family coverage
you have self-only coverage, your
maximum contribution is $3,050. If you
Enter $6,150 on the line below for the
Enter $3,050 on the line below for the
have family coverage, your maximum
month. If you were age 55 or older at the
month. If, at the end of 2010, you were
contribution is $6,150.
end of 2010, enter $4,050 for the month.
unmarried and age 55 or older, enter
$7,150 for the month.
Note. If you are age 55 or older at the
end of 2010, you can make an
additional contribution of $1,000.
Your maximum contribution is
reduced by any employer contributions
Amount from
to your HSA, any contributions made to
chart above
Month in 2010
your Archer MSA, and any qualified
HSA funding distributions.
January
You can make deductible
contributions to your HSA even if your
February
employer made contributions. However,
if you (or someone on your behalf)
March
made contributions in addition to any
employer contributions and qualified
April
HSA funding distributions, you may
have to pay an additional tax. See
May
Excess Contributions You Make on
page 5.
June
You cannot deduct any contributions
July
for any month in which you were
enrolled in Medicare. Also, you cannot
August
deduct contributions if you can be
claimed as a dependent on someone
September
else’s 2010 tax return.
October
November
December
Total for all months
Limitation. Divide the total by 12. Enter here and on line 3
-3-
Form 8889 (2010)
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