Instructions For Form 8889 - Health Savings Accounts - 2011 Page 3

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Specific Instructions
Line 3 Limitation Chart and Worksheet
Name and social security number
(SSN). Enter your name(s) as shown
Before you begin: See the instructions for line 3 on page 4.
on your tax return and the SSN of the
Go through this chart for each month of 2011.
HSA beneficiary. If married filing jointly
(Keep for your records)
and both you and your spouse have
HSAs, complete a separate Form 8889
Start Here
for each of you.
Were you enrolled in Medicare for the
Yes
Part I—HSA
month?
Contributions and
No
Deductions
Use Part I to figure:
Were you an eligible individual (see
Your HSA deduction,
page 1) on the first day of the month
Enter -0- on the line
Any excess contributions you made
No
(see the line 3 instructions on page 4)?
below for the month.
(or those made on your behalf), and
Any excess contributions made by an
employer (see Excess Employer
Contributions beginning on page 5).
Yes
Figuring Your HSA
Deduction
What type of coverage did your HDHP provide on the first
day of the month?
The maximum amount that can be
contributed to your HSA depends on
the type of HDHP coverage you have. If
you have self-only coverage, your
maximum contribution is $3,050. If you
Self-only coverage
Family coverage
have family coverage, your maximum
Enter $6,150 on the line below for the
Enter $3,050 on the line below for the
contribution is $6,150.
month. If, at the end of 2011, you were
month. If you were age 55 or older at the
Note. If you are age 55 or older at the
unmarried and age 55 or older, enter
end of 2011, enter $4,050 for the month.
end of your tax year, you can make an
$7,150 for the month.
additional contribution of $1,000.
Your maximum contribution is
reduced by any employer contributions
to your HSA, any contributions made to
Amount from
your Archer MSA, and any qualified
chart above
Month in 2011
HSA funding distributions.
You can make deductible
contributions to your HSA even if your
January
employer made contributions. However,
if you (or someone on your behalf)
February
made contributions in addition to any
March
employer contributions and qualified
HSA funding distributions, you may
April
have to pay an additional tax. See
Excess Contributions You Make on
May
page 5.
You cannot deduct any contributions
June
for any month in which you were
enrolled in Medicare. Also, you cannot
July
deduct contributions if you can be
claimed as a dependent on someone
August
else’s 2011 tax return.
September
How To Complete Part I
Complete lines 1 through 13 as
October
instructed on the form. However, if you,
and your spouse if filing jointly, are both
November
eligible individuals and either of you
December
have an HDHP with family coverage,
you both are treated as having only the
Total for all months
family coverage plan. Disregard any
plans with self-only coverage.
Limitation. Divide the total by 12. Enter here and on line 3
Complete a separate Form 8889 for
each spouse. Combine the amounts on
line 13 of both Forms 8889 and enter
-3-
Form 8889 (2011)

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