Instructions For Form 8889 - Health Savings Accounts

How To Complete Part I

4. If you were, or were considered,

your contribution limit is $6,150 (the

an eligible individual for the entire year

family coverage maximum). You and

Complete lines 1 through 13 as

and you changed your type of coverage

your spouse can divide this amount in

instructed on the form. However, if you,

during the year, enter on line 3 (see (6)

any allocation to which you agree (such

and your spouse if filing jointly, are both

below) the greater of:

as allocating nothing to one spouse).

eligible individuals and either of you

•

a. The limitation shown on the last

If you are not treated as having

have an HDHP with family coverage,

line of the Line 3 Limitation Chart and

family coverage for each month, use

you both are treated as having only the

Worksheet on page 3, or

the following steps to determine the

family coverage plan. Disregard any

b. The maximum amount that can

amount to enter on line 6.

plans with self-only coverage.

be contributed based on the type of

Step 1. Refigure the contribution

Complete a separate Form 8889 for

HDHP coverage you had on the first

limit that would have been entered on

each spouse. Combine the amounts on

day of the last month of your tax year.

line 5 if you had entered on line 3 the

line 13 of both Forms 8889 and enter

total of the worksheet amounts only for

If you had family coverage on

this amount on Form 1040, line 25; or

the months you were treated as having

the first day of the last month,

TIP

Form 1040NR, line 25. Be sure to

family coverage. When refiguring line 5,

you do not need to use the

attach both Forms 8889 to your tax

use the same amount you previously

worksheet; enter $6,150 on line 3.

return.

entered on line 4.

5. If you were not an eligible

Line 1

Step 2. Divide the refigured

individual on the first day of the last

contribution limit from Step 1 equally

month of your tax year, use the Line 3

If you were covered, or considered

between you and your spouse, unless

Limitation Chart and Worksheet on

covered, by a self-only HDHP and a

you both agree on a different allocation

page 3 to determine the amount to

family HDHP at different times during

(such as allocating nothing to one

enter on line 3. (See (6) below.)

the year, check the box for the plan that

spouse).

6. If, at the end of 2010, you were

was in effect for a longer period. If you

Step 3. Subtract the part of the

age 55 or older and unmarried or

were covered by both a self-only HDHP

contribution limit allocated to your

married with self-only HDHP coverage

and a family HDHP at the same time,

spouse in Step 2 from the amount

for the entire year, you can increase the

you are treated as having family

determined in Step 1.

amount determined in (3) or (4) by

coverage during that period. If, on the

$1,000 (the additional contribution

Step 4. Determine any other

first day of the last month of your tax

amount). For (5), the additional

contribution limits that apply for the tax

year, December 1 for most taxpayers,

contribution amount is taken into

year and add that amount to the result

you had family coverage, check the

account for each month you are an

in Step 3. Enter the total on line 6.

“family” box.

eligible individual.

Example. In 2010, you are an

Line 2

eligible individual and have family

Note. If you are married and had

Include on line 2 only those amounts

HDHP coverage. In March you divorce

family coverage at any time during the

you, or others on your behalf,

and change your coverage as of April 1

year, the additional contribution amount

contributed to your HSA. Also, include

to self-only. Neither you nor your

is figured on line 7 and is not included

those contributions made from January

ex-spouse qualify for the additional

on line 3.

1, 2011, through April 18, 2011, that

contribution amount. Your ex-spouse

were for 2010. Do not include employer

continued to have family HDHP

See Pub. 969 for more information.

contributions (see line 9) or amounts

coverage and was an eligible individual

If you must complete the line 3

rolled over from another HSA or Archer

for the entire year. The contribution limit

worksheet, and your eligibility

MSA, or a qualified HSA distribution.

TIP

for the 3 months you both were

and coverage did not change

See Rollovers on page 2. Also, do not

considered to have family coverage is

from one month to the next, enter the

include any qualified HSA funding

$1,537.50 ($6,150 × 3 ÷ 12). You and

same number you entered for the

distributions (see line 10). Contributions

your ex-spouse decide to divide the

previous month.

to an employee’s account through a

family coverage contribution in the

cafeteria plan are treated as employer

following manner: 75% to your

Line 6

contributions and are not included on

ex-spouse and 25% to you. Your

Spouses who have separate HSAs and

line 2.

contribution limit for 9 months of

had family coverage under an HDHP at

self-only coverage is $2,287.50 ($3,050

Line 3

any time during 2010, use the following

× 9 ÷ 12). This amount is not divided

rules to figure the amount on line 6.

between you and your spouse.

When figuring the amount to enter on

•

If you are treated as having family

line 3, apply the following rules.

Because you are covered under a

coverage for each month, divide the

1. Use the family coverage amount

self-only policy on December 1, you will

amount on line 5 equally between you

if you or your spouse had an HDHP

show $3,050 on line 6 (the greater of

and your spouse, unless you both

with family coverage. Disregard any

either (a) $2,671.87 ($1,537.50 family

agree on a different allocation (such as

plan with self-only coverage.

coverage + $2,287.50 self-only

allocating nothing to one spouse). Enter

2. If the last-month rule (see page

coverage – $1,153.13 spousal

your allocable share on line 6.

1) applies, you are considered an

allocation) or (b) the maximum amount

Example. In 2010, you are an

eligible individual for the entire year.

that can be contributed ($3,050 for

You are treated as having the same

eligible individual and have self-only

self-only coverage)). Your ex-spouse

HDHP coverage for the entire year as

HDHP coverage. In March you marry

would show $6,150 on line 6 (the

you had on the first day of the last

and as of April 1 you have family HDHP

greater of either (a) $5,765.63

month of your tax year.

coverage. Neither you nor your spouse

($1,537.50 family coverage for the 3

3. If you were, or were considered,

qualify for the additional contribution

months prior to the divorce + $4,612.50

an eligible individual for the entire year

amount. Your spouse has a separate

family coverage maintained after the

and you did not change your type of

HSA and is an eligible individual from

divorce – $384.37 spousal allocation)

coverage, enter $3,050 for a self-only

April 1 to December 31, 2010. Because

or (b) the maximum amount that can be

HDHP or $6,150 for a family HDHP on

you and your spouse are considered to

contributed ($6,150 for family

line 3. (See (6) below.)

have family coverage on December 1,

coverage)).

-4-

Form 8889 (2010)

Instructions For Form 8889 - Health Savings Accounts - 2010 Page 4

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