Instructions For Form 8889 - Health Savings Accounts

Line 7

Employer Contributions beginning on

funding distribution in income in the

this page.

year in which you fail to be an eligible

individual. This amount is also subject

Additional Contribution Amount

Line 10

to a 10% additional tax. (See Part III.)

If, at the end of 2010, you were age 55

Enter on line 10 any qualified HSA

or older and married, use the Additional

Line 13

funding distribution made during the

Contribution Amount Worksheet on this

year. This is a distribution from your

If you or someone on your behalf (or

page if both of the following apply.

traditional IRA or Roth IRA to your HSA

your employer) contributed more to

1. You or your spouse had family

in a direct trustee-to-trustee transfer.

your HSA than is allowable, you may

coverage under an HDHP and were, or

This distribution is not included in your

have to pay an additional tax on the

were considered to be, an eligible

income, is not deductible, and reduces

excess contributions. Figure the excess

individual on the first day of the month.

the amount that can be contributed to

contributions using the instructions

2. You were not enrolled in

your HSA. This distribution cannot be

below. See Form 5329, Additional

Medicare for the month.

made from an ongoing SEP IRA or

Taxes on Qualified Plans (Including

SIMPLE IRA. For this purpose, a SEP

IRAs) and Other Tax-Favored

Enter the result on line 7.

IRA or SIMPLE IRA is ongoing if an

Accounts, to figure the additional tax.

employer contribution is made for the

If items (1) and (2) apply to all

plan year ending with or within your tax

Excess Contributions You Make

months during 2010, enter

TIP

year in which the distribution would be

To figure your excess contributions

$1,000 on line 7.

made.

(including those made on your behalf),

Additional Contribution Amount

The maximum amount that can be

subtract your deductible contributions

Worksheet

(line 13) from your actual contributions

excluded from income is based on your

(line 2). However, you can withdraw

age at the end of the year and your

1. $1,000 × number of months

some or all of your excess contributions

HDHP coverage (self-only or family) at

eligible . . . . . . . . . . . . . . . . .

for 2010 and they will be treated as if

the time of the distribution. You can

2. Divide line 1 by 12. Enter here

make only one qualified HSA funding

they had not been contributed if:

and on line 7 . . . . . . . . . . . . .

•

distribution during your lifetime.

You make the withdrawal by the due

However, if you make the distribution

date, including extensions, of your 2010

Example. At the end of 2010, you

during a month when you have

tax return (but see the Note under

were age 55 and married. You had

self-only HDHP coverage, you can

Excess Employer Contributions below),

•

family coverage under an HDHP from

make another qualified HSA funding

You do not claim a deduction for the

January 1 through June 30, 2010 (6

distribution in a later month in that tax

amount of the withdrawn contributions,

months). You were not enrolled in

year if you change to family HDHP

and

Medicare in 2010. You would enter an

•

coverage.

You also withdraw any income

additional contribution amount of $500

earned on the withdrawn contributions

A qualified HSA funding distribution

on line 7 ($1,000 × 6 ÷ 12).

and include the earnings in “Other

made during your tax year reduces the

income” on your tax return for the year

amount that can be contributed from

Line 9

you withdraw the contributions and

other sources (including employer

earnings.

contributions) to your HSA. See the

Employer Contributions

discussions under Line 13 for the

Excess Employer Contributions

Employer contributions (including

treatment of excess contributions.

contributions through a cafeteria plan)

Excess employer contributions are the

See Pub. 969 for more information.

include any amount an employer

excess, if any, of your employer’s

contributes to any HSA for you for

Testing period. You must remain

contributions over your limitation on line

2010. These contributions should be

an eligible individual during the testing

8. If you made a qualified HSA funding

shown in box 12 of Form W-2 with code

period. The testing period begins with

distribution (line 10) during the tax year,

W. If either of the following apply,

the month in which the qualified HSA

reduce your limitation (line 8) by that

complete the Employer Contribution

funding distribution is contributed to the

distribution before you determine

Worksheet below.

HSA and ends on the last day of the

whether you have excess employer

•

Employer contributions for 2009 are

12th month following that month. For

contributions. If the excess was not

included in the amount reported in box

example, if the distribution is

included in income on Form W-2, you

12 of Form W-2 with code W.

contributed on June 14, 2010, the

must report it as “Other income” on

•

Employer contributions for 2010 are

testing period ends on June 30, 2011. If

your tax return. However, you can

made in 2011.

you fail to remain an eligible individual

withdraw some or all of the excess

If your employer made excess

during this period, other than because

employer contributions for 2010 and

contributions, you may have to report

of death or becoming disabled, you will

they will be treated as if they had not

the excess as income. See Excess

have to include the qualified HSA

been contributed if:

Employer Contribution Worksheet

Keep for Your Records

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

2. Enter employer contributions made in 2010 for tax year 2009 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

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

4. Enter employer contributions made in 2011 for tax year 2010 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

5. Employer contributions for 2010. Add lines 3 and 4. Enter here and on Form 8889, line 9 . . . . . . . . . . . . . .

-5-

Form 8889 (2010)

Instructions For Form 8889 - Health Savings Accounts - 2010 Page 5

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