Instructions For Form 8889 - Health Savings Accounts - 2011 Page 5

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2. You were not enrolled in
the amount that can be contributed to
your HSA than is allowable, you may
Medicare for the month.
your HSA. This distribution cannot be
have to pay an additional tax on the
excess contributions. Figure the excess
made from an ongoing SEP IRA or
contributions using the instructions
SIMPLE IRA. For this purpose, a SEP
Enter the result on line 7.
below. See Form 5329, Additional
IRA or SIMPLE IRA is ongoing if an
Taxes on Qualified Plans (Including
If items (1) and (2) apply to all
employer contribution is made for the
IRAs) and Other Tax-Favored
months during 2011, enter
plan year ending with or within your tax
TIP
$1,000 on line 7.
Accounts, to figure the additional tax.
year in which the distribution would be
made.
Excess Contributions You Make
Additional Contribution Amount
To figure your excess contributions
Worksheet
The maximum amount that can be
(including those made on your behalf),
excluded from income is based on your
subtract your deductible contributions
age at the end of the year and your
1. $1,000 × number of months
(line 13) from your actual contributions
HDHP coverage (self-only or family) at
eligible . . . . . . . . . . . . . . . . .
(line 2). However, you can withdraw
the time of the distribution. You can
2. Divide line 1 by 12. Enter here
some or all of your excess contributions
and on line 7 . . . . . . . . . . . . .
make only one qualified HSA funding
for 2011 and they will be treated as if
distribution during your lifetime.
they had not been contributed if:
Example. At the end of 2011, you
However, if you make the distribution
You make the withdrawal by the due
were age 55 and married. You had
during a month when you have
date, including extensions, of your 2011
family coverage under an HDHP from
self-only HDHP coverage, you can
tax return (but see the Note under
January 1 through June 30, 2011 (6
make another qualified HSA funding
Excess Employer Contributions on the
months). You were not enrolled in
distribution in a later month in that tax
next page),
Medicare in 2011. You would enter an
year if you change to family HDHP
You do not claim a deduction for the
additional contribution amount of $500
coverage.
amount of the withdrawn contributions,
on line 7 ($1,000 × 6 ÷ 12).
and
A qualified HSA funding distribution
You also withdraw any income
Line 9
made during your tax year reduces the
earned on the withdrawn contributions
amount that can be contributed from
and include the earnings in “Other
Employer Contributions
other sources (including employer
income” on your tax return for the year
contributions) to your HSA. See the
Employer contributions (including
you withdraw the contributions and
discussions under Line 13 for the
contributions through a cafeteria plan)
earnings.
treatment of excess contributions.
include any amount an employer
Excess Employer Contributions
contributes to any HSA for you for
See Pub. 969 for more information.
2011. These contributions should be
Excess employer contributions are the
shown in box 12 of Form W-2 with code
excess, if any, of your employer’s
Testing period. You must remain
W. If either of the following apply,
contributions over your limitation on line
an eligible individual during the testing
complete the Employer Contribution
8. If you made a qualified HSA funding
period. The testing period begins with
Worksheet below.
distribution (line 10) during the tax year,
the month in which the qualified HSA
Employer contributions for 2010 are
reduce your limitation (line 8) by that
funding distribution is contributed to the
included in the amount reported in box
distribution before you determine
HSA and ends on the last day of the
12 of Form W-2 with code W.
whether you have excess employer
12th month following that month. For
Employer contributions for 2011 are
contributions. If the excess was not
example, if the distribution is
made in 2012.
included in income on Form W-2, you
contributed on June 14, 2011, the
If your employer made excess
must report it as “Other income” on
testing period ends on June 30, 2012. If
contributions, you may have to report
your tax return. However, you can
you fail to remain an eligible individual
the excess as income. See Excess
withdraw some or all of the excess
during this period, other than because
Employer Contributions beginning on
employer contributions for 2011 and
of death or becoming disabled, you will
this page.
they will be treated as if they had not
have to include the qualified HSA
been contributed if:
funding distribution in income in the
Line 10
year in which you fail to be an eligible
Enter on line 10 any qualified HSA
individual. This amount is also subject
funding distribution made during the
to a 10% additional tax. (See Part III.)
year. This is a distribution from your
traditional IRA or Roth IRA to your HSA
Line 13
in a direct trustee-to-trustee transfer.
If you or someone on your behalf (or
This distribution is not included in your
your employer) contributed more to
income, is not deductible, and reduces
Employer Contribution Worksheet
Keep for Your Records
1. Enter the employer contributions reported in box 12 of Form W-2, with code W . . . . . . . . . . . . . . . . . . . . . . .
1.
2. Enter employer contributions made in 2011 for tax year 2010 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
2.
3. Subtract line 2 from line 1 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
3.
4. Enter employer contributions made in 2012 for tax year 2011 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
4.
5. Employer contributions for 2011. Add lines 3 and 4. Enter here and on Form 8889, line 9 . . . . . . . . . . . . . .
5.
-5-
Form 8889 (2011)

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