Instructions For Form 8889 - Health Savings Accounts

•

You make the withdrawal by the due

included on line 14a that were

check the box on line 17a. Enter on line

date, including extensions, of your 2011

withdrawn by the due date, including

17b only 20% (.20) of any amount

tax return (but see the Note below),

extensions, of your return. See the

included on line 16 that does not meet

•

You do not claim an exclusion from

instructions for line 13 on page 5.

any of the exceptions.

income for the amount of the withdrawn

Example 1. You turned age 63 in

Line 15

contributions, and

2011 and received a distribution from

•

You also withdraw any income

an HSA that is included in income. Do

Only include on line 15

earned on the withdrawn contributions

not check the box on line 17a because

distributions from your HSA that

and include the earnings in “Other

you (the account beneficiary) did not

were used to pay you for

income” on your tax return for the year

CAUTION

meet the age exception for the

qualified medical expenses (see page

you withdraw the contributions and

distribution. Enter 20% of the amount

1) not reimbursed by insurance or other

earnings.

from line 16 on line 17b.

coverage and that you incurred after

Note. If you timely filed your return

Example 2. You turned age 65 in

the HSA was established. Do not

without withdrawing the excess

2011. You received distributions that

include the distribution of an excess

contributions, you can still make the

are included in income both before and

contribution taken out after the due

withdrawal no later than 6 months after

after you turned age 65. Check the box

date, including extensions, of your

the due date of your tax return,

on line 17a because the additional 20%

return even if used for qualified medical

excluding extensions. If you do, file an

tax does not apply to the distributions

expenses.

amended return with “Filed pursuant to

made after the date you turned age 65.

In general, include on line 15

section 301.9100-2” written at the top.

However, the additional 20% tax does

distributions from all HSAs in 2011 that

Include an explanation of the

apply to the distributions made on or

were used for the qualified medical

withdrawal. Make all necessary

before the date you turned age 65.

expenses (see page 1) of:

changes on the amended return (for

Enter on line 17b, 20% of the amount of

example, if you reported the

1. Yourself and your spouse.

these distributions included in line 16.

contributions as excess contributions

2. All dependents you claim on your

Part III—Income and

on your original return, include an

tax return.

amended Form 5329 reflecting that the

3. Any person you could have

Additional Tax for

withdrawn contributions are no longer

claimed as a dependent on your return

treated as having been contributed).

except that:

Failure to Maintain HDHP

a. The person filed a joint return.

Deducting an Excess

Coverage

b. The person had gross income of

Contribution in a Later Year

$3,700 or more.

Use Part III to figure any income and

c. You, or your spouse if filing

You may be able to deduct excess

additional tax that must be reported on

jointly, could be claimed as a

contributions for previous years that are

Form 1040 or Form 1040NR for failure

dependent on someone else’s return.

still in your HSA. The excess

to be an eligible individual during the

contributions you can deduct in the

testing period for:

current year is the lesser of the

For this purpose, a child of

•

A qualified HSA distribution (see

following two amounts.

parents that are divorced,

TIP

page 2),

•

Your maximum HSA contribution limit

separated, or living apart for the

•

Last-month rule (see page 1), and

for the year minus any amounts

last 6 months of the calendar year is

•

A qualified HSA funding distribution

treated as the dependent of both

contributed to your HSA for the year.

(see page 5).

•

parents whether or not the custodial

The total excess contributions in your

See the discussions on the pages

HSA at the beginning of the year.

parent releases the claim to the child’s

indicated to determine the testing

exemption.

Any excess contribution remaining at

period for each of these items. Include

the end of the tax year is subject to the

You cannot take a deduction on

the amount in income in the year in

additional tax. See Form 5329.

Schedule A (Form 1040) for any

which you fail to be an eligible

amount you include on line 15.

individual.

Part II—HSA

CAUTION

Line 18

Lines 17a and 17b

Distributions

Enter the total of any qualified HSA

Additional 20% Tax

distribution.

Line 14a

HSA distributions included in income

Line 19

Enter the total distributions you

(line 16) are subject to an additional

received in 2011 from all HSAs. Your

You can use the Line 3 Limitation Chart

20% tax unless one of the following

total distributions include amounts paid

and Worksheet in the Instructions for

exceptions applies.

with a debit card that restricts payments

Form 8889 for the year the contribution

Exceptions to the Additional

to health care and amounts withdrawn

was made to determine the contribution

20% Tax

by other individuals that you have

you could have made if the last-month

designated. These amounts should be

rule did not apply. Enter on line 19 the

The additional 20% tax does not apply

shown in box 1 of Form 1099-SA.

excess of the amount contributed over

to distributions made after the account

the redetermined amount. Examples of

beneficiary —

Line 14b

•

this computation are in Pub. 969.

Dies,

•

Include on line 14b any distributions

Becomes disabled (see page 2), or

Line 20

•

you received in 2011 that qualified as a

Turns age 65.

rollover contribution to another HSA.

Enter the total of any qualified HSA

If any of the exceptions apply to any

See Rollovers on page 2. Also include

funding distribution.

of the distributions included on line 16,

any excess contributions (and the

earnings on those excess contributions)

-6-

Form 8889 (2011)

Instructions For Form 8889 - Health Savings Accounts - 2011 Page 6

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