Instructions For Form 8889 - Health Savings Accounts - 2011 Page 4

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this amount on Form 1040, line 25; or
If you had family coverage on
the months you were treated as having
Form 1040NR, line 25. Be sure to
the first day of the last month,
family coverage. When refiguring line 5,
TIP
attach both Forms 8889 to your tax
you do not need to use the
use the same amount you previously
return.
worksheet; enter $6,150 on line 3.
entered on line 4.
5. If you were not an eligible
Step 2. Divide the refigured
Line 1
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 2011, 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
Step 4. Determine any other
$1,000 (the additional contribution
first day of the last month of your tax
contribution limits that apply for the tax
amount). For (5), the additional
year, December 1 for most taxpayers,
year and add that amount to the result
contribution amount is taken into
you had family coverage, check the
in Step 3. Enter the total on line 6.
account for each month you are an
“family” box.
eligible individual.
Example. In 2011, you are an
Line 2
Note. If you are married and had
eligible individual and have family
family coverage at any time during the
HDHP coverage. In March you divorce
Include on line 2 only those amounts
year, the additional contribution amount
and change your coverage as of April 1
you, or others on your behalf,
is figured on line 7 and is not included
to self-only. Neither you nor your
contributed to your HSA. Also, include
on line 3.
ex-spouse qualify for the additional
those contributions made from January
contribution amount. Your ex-spouse
1, 2012, through April 17, 2012, that
See Pub. 969 for more information.
continued to have family HDHP
were for 2011. Do not include employer
coverage and was an eligible individual
contributions (see line 9) or amounts
If you must complete the line 3
for the entire year. The contribution limit
rolled over from another HSA or Archer
worksheet, and your eligibility
TIP
for the 3 months you both were
MSA, or a qualified HSA distribution.
and coverage did not change
considered to have family coverage is
See Rollovers on page 2. Also, do not
from one month to the next, enter the
$1,537.50 ($6,150 × 3 ÷ 12). You and
include any qualified HSA funding
same number you entered for the
your ex-spouse decide to divide the
distributions (see line 10). Contributions
previous month.
family coverage contribution in the
to an employee’s account through a
Line 6
following manner: 75% to your
cafeteria plan are treated as employer
ex-spouse and 25% to you. Your
contributions and are not included on
Spouses who have separate HSAs and
contribution limit for 9 months of
line 2.
had family coverage under an HDHP at
self-only coverage is $2,287.50 ($3,050
any time during 2011, use the following
× 9 ÷ 12). This amount is not divided
Line 3
rules to figure the amount on line 6.
between you and your spouse.
If you are treated as having family
When figuring the amount to enter on
coverage for each month, divide the
Because you are covered under a
line 3, apply the following rules.
amount on line 5 equally between you
self-only policy on December 1, you will
1. Use the family coverage amount
and your spouse, unless you both
show $3,050 on line 6 (the greater of
if you or your spouse had an HDHP
agree on a different allocation (such as
either (a) $2,671.87 ($1,537.50 family
with family coverage. Disregard any
allocating nothing to one spouse). Enter
coverage + $2,287.50 self-only
plan with self-only coverage.
your allocable share on line 6.
coverage – $1,153.13 spousal
2. If the last-month rule (see page
allocation) or (b) the maximum amount
Example. In 2011, you are an
1) applies, you are considered an
that can be contributed ($3,050 for
eligible individual and have self-only
eligible individual for the entire year.
self-only coverage)). Your ex-spouse
HDHP coverage. In March you marry
You are treated as having the same
would show $6,150 on line 6 (the
and as of April 1 you have family HDHP
HDHP coverage for the entire year as
greater of either (a) $5,765.63
coverage. Neither you nor your spouse
you had on the first day of the last
($1,537.50 family coverage for the 3
qualify for the additional contribution
month of your tax year.
months prior to the divorce + $4,612.50
amount. Your spouse has a separate
3. If you were, or were considered,
family coverage maintained after the
HSA and is an eligible individual from
an eligible individual for the entire year
divorce – $384.37 spousal allocation)
April 1 to December 31, 2011. Because
and you did not change your type of
or (b) the maximum amount that can be
you and your spouse are considered to
coverage, enter $3,050 for a self-only
contributed ($6,150 for family
have family coverage on December 1,
HDHP or $6,150 for a family HDHP on
coverage)).
your contribution limit is $6,150 (the
line 3. (See (6) below.)
family coverage maximum). You and
4. If you were, or were considered,
Line 7
your spouse can divide this amount in
an eligible individual for the entire year
any allocation to which you agree (such
and you changed your type of coverage
Additional Contribution Amount
as allocating nothing to one spouse).
during the year, enter on line 3 (see (6)
If you are not treated as having
If, at the end of 2011, you were age 55
below) the greater of:
family coverage for each month, use
or older and married, use the Additional
a. The limitation shown on the last
the following steps to determine the
Contribution Amount Worksheet on the
line of the Line 3 Limitation Chart and
amount to enter on line 6.
next page if both of the following apply.
Worksheet on page 3, or
Step 1. Refigure the contribution
b. The maximum amount that can
1. You or your spouse had family
be contributed based on the type of
limit that would have been entered on
coverage under an HDHP and were, or
HDHP coverage you had on the first
line 5 if you had entered on line 3 the
were considered to be, an eligible
day of the last month of your tax year.
total of the worksheet amounts only for
individual on the first day of the month.
-4-
Form 8889 (2011)

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