Instructions For Form 8889 - Health Savings Accounts

you previously entered on line 5.

an amended return with “Filed

Line 11

Enter the result on line 6.

pursuant to section 301.9100-2”

If you or someone on your behalf (or

written at the top. Include an

Example. In 2005, you are an

your employer) contributed more to

explanation of the withdrawal. Make

eligible individual and have self-only

your HSA than is allowable, you may

all necessary changes on the

coverage under an HDHP with a

have to pay an additional tax on the

amended return (for example, if you

$1,200 deductible. In March, you get

excess contributions. Figure the

reported the contributions as excess

married and as of April 1, you have

excess contributions using the

contributions on your original return,

family coverage under an HDHP with

instructions below. See Form 5329,

include an amended Form 5329

a $2,400 deductible. Neither you nor

Additional Taxes on Qualified Plans

reflecting that the withdrawn

your spouse were age 55 or older at

(Including IRAs) and Other

contributions are no longer treated as

the end of 2005 so you do not qualify

Tax-Favored Accounts, to figure the

having been contributed).

for the additional contribution amount.

additional tax.

Your spouse has a separate HSA and

Part II—HSA

is an eligible individual from April 1

Excess Contributions You Make

through December 31, 2005. The

Distributions

To figure your excess contributions

contribution limit for the 9 months of

(including those made on your

family coverage is $1,800 ($2,400 ×

behalf), subtract your deductible

Line 12a

9/12). You and your spouse can

contributions (line 11) from your

Enter the total distributions you

divide the $1,800 in any allocation

actual contributions (line 2). However,

received in 2005 from all HSAs.

you agree to. Your contribution limit

you can withdraw some or all of your

These amounts should be shown in

for the 3 months of self-only coverage

excess contributions for 2005 and

is $300 ($1,200 × 3/12). This amount

box 1 of Form 1099-SA.

they will be treated as if they had not

is not divided between you and your

been contributed if:

spouse. If you and your spouse divide

Line 12b

•

You make the withdrawal by the

the contribution limit for the months of

Include on line 12b any distributions

due date, including extensions, of

family coverage equally, you will

you received in 2005 that qualified as

your 2005 tax return (but see the

show $1,200 on line 6 ($2,100 from

a rollover contribution to another

Note below),

your original line 5 minus $900

•

HSA. See Rollovers on page 2. Also

You do not claim a deduction for

allocated to your spouse). Your

include any excess contributions (and

the amount of the withdrawn

spouse will show $900 on line 6.

the earnings on those excess

contributions, and

•

contributions) included on line 12a

Line 7

You also withdraw any income

that were withdrawn by the due date,

earned on the withdrawn

including extensions, of your return.

Additional Contribution Amount

contributions and include the

See the instructions for line 11 on this

earnings in “Other income” on your

If, at the end of 2005, you were age

page.

tax return for the year you withdraw

55 or older and married, multiply $50

the contributions and earnings.

by the number of months during 2005

Line 13

that both of the following apply.

Excess Employer Contributions

1. You or your spouse had family

Only include on line 13

Excess employer contributions are

coverage under an HDHP on the first

distributions from your HSA

the excess, if any, of your employer’s

day of the month.

that were used to pay or

CAUTION

contributions over your limitation on

2. You were not enrolled in

reimburse qualified medical expenses

line 8. If the excess was not included

Medicare for the month.

(see page 1) you incurred on or after

in income on Form W-2, you must

the first day of the first month you

Enter the result on line 7.

report it as “Other income” on your

became an eligible individual (see

tax return. However, you can

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

page 1).

withdraw some or all of the excess

TIP

months during 2005, enter

employer contributions for 2005 and

In general, include on line 13

$600 on line 7.

they will be treated as if they had not

distributions from all HSAs in 2005

been contributed if:

Example. At the end of 2005, you

that were used for the qualified

•

You make the withdrawal by the

were age 55 and married. You had

medical expenses (see page 1) of:

due date, including extensions, of

•

family coverage under an HDHP from

Yourself and your spouse.

your 2005 tax return (but see the

July 1 through December 31, 2005 (6

•

All dependents you claim on your

Note below),

months). You were not enrolled in

•

tax return.

Medicare in 2005. You would enter

You do not claim an exclusion from

•

Any person you could have

an additional contribution amount of

income for the amount of the

$300 on line 7 ($50 × 6 months).

claimed as a dependent on your

withdrawn contributions, and

•

return except that person received

You also withdraw any income

Line 9

$3,200 or more of gross income or

earned on the withdrawn

filed a joint return.

contributions and include the

•

Employer Contributions

Any person you could have

earnings in “Other income” on your

claimed as a dependent except that

Employer contributions include any

tax return for the year you withdraw

you, or your spouse if filing jointly,

amount an employer contributes to

the contributions and earnings.

were claimed as a dependent on

any HSA for you for 2005. These

someone else’s 2005 return.

contributions should be shown in box

Note. If you timely filed your return

without withdrawing the excess

12 of Form W-2 with code W. If your

You cannot take a deduction

employer made excess contributions,

contributions, you can still make the

you may have to report the excess as

withdrawal no later than 6 months

on Schedule A (Form 1040)

for any amount you include on

income. See Excess Employer

after the due date of your tax return,

CAUTION

line 13.

Contributions on this page for details.

excluding extensions. If you do, file

-4-

Instructions For Form 8889 - Health Savings Accounts - 2005 Page 4

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