Instructions For Form 8889 - Health Savings Accounts Hsas

10% tax unless one of the following

period for each of these items. Include

Part II—HSA

exceptions apply.

the amount in income in the year in

Distributions

which you fail to be an eligible

Exceptions to the Additional

individual.

10% Tax

Line 14a

Line 18

The additional 10% tax does not apply

Enter the total distributions you

to distributions made after the account

Enter the total of any qualified HSA

received in 2007 from all HSAs. These

beneficiary —

distribution.

•

amounts should be shown in box 1 of

Dies,

•

Line 19

Form 1099-SA.

Becomes disabled (see page 2), or

•

Turns age 65.

You can use the Line 3 Limitation Chart

Line 14b

and Worksheet in the Instructions for

If any of the exceptions apply to any

Include on line 14b any distributions

Form 8889 for the year the contribution

of the distributions included on line 16,

you received in 2007 that qualified as a

was made to determine the contribution

check the box on line 17a. Enter on line

rollover contribution to another HSA.

you could have made if the last-month

17b only 10% (.10) of any amount

See Rollovers on page 2. Also include

rule did not apply. Enter the excess of

included on line 16 that does not meet

any excess contributions (and the

the amount contributed over the

any of the exceptions.

earnings on those excess contributions)

redetermined amount on line 13.

Example 1. You turned age 63 in

included on line 14a that were

2007 and received a distribution from

Line 20

withdrawn by the due date, including

an HSA that is included in income. Do

extensions, of your return. See the

Enter the total of any qualified HSA

not check the box on line 17a because

instructions for line 13 on page 5.

funding distribution.

you (the account beneficiary) did not

Line 15

meet the age exception for the

Paperwork Reduction Act Notice.

distribution. Enter 10% of the amount

We ask for the information on this form

Only include on line 15

from line 16 on line 17b.

to carry out the Internal Revenue laws

distributions from your HSA that

of the United States. You are required

Example 2. You turned age 65 in

were used to pay or reimburse

CAUTION

to give us the information. We need it to

2007. You received distributions that

you for qualified medical expenses (see

are included in income both before and

ensure that you are complying with

page 1) you incurred after the HSA was

after you turned age 65. Check the box

these laws and to allow us to figure and

established. Do not include the

on line 17a because the additional 10%

collect the right amount of tax.

distribution of an excess contribution

tax does not apply to the distributions

You are not required to provide the

taken out after the due date, including

made after the date you turned age 65.

information requested on a form that is

extensions, of your return even if used

However, the additional 10% tax does

subject to the Paperwork Reduction Act

for qualified medical expenses.

apply to the distributions made on or

unless the form displays a valid OMB

In general, include on line 15

before the date you turned age 65.

control number. Books or records

distributions from all HSAs in 2007 that

Enter on line 17b, 10% of the amount of

relating to a form or its instructions

were used for the qualified medical

these distributions included in line 16.

must be retained as long as their

expenses (see page 1) of:

contents may become material in the

Part III—Income and

1. Yourself and your spouse.

administration of any Internal Revenue

2. All dependents you claim on your

law. Generally, tax returns and return

Additional Tax for

information are confidential, as required

tax return.

Failure to Maintain HDHP

by section 6103.

3. Any person you could have

claimed as a dependent on your return

The average time and expenses

Coverage

except that:

required to complete and file this form

Use Part III to figure any income and

will vary depending on individual

a. The person filed a joint return.

additional tax that must be reported on

b. The person had gross income of

circumstances. For the estimated

Form 1040 or Form 1040NR for failure

$3,400 or more.

averages, see the instructions for your

to be an eligible individual during the

c. You, or your spouse if filing

income tax return.

testing period for:

jointly, could be claimed as a

If you have suggestions for making

•

A qualified HSA distribution (see

dependent on someone else’s return.

this form simpler, we would be happy to

page 2),

hear from you. See the instructions for

•

Part-year coverage (see Last-month

You cannot take a deduction on

your income tax return.

rule on page 1), and

Schedule A (Form 1040) for any

•

A qualified HSA funding distribution

amount you include on line 15.

CAUTION

(see page 5).

Lines 17a and 17b

See the discussions on the pages

indicated to determine the testing

Additional 10% Tax

HSA distributions included in income

(line 16) are subject to an additional

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Instructions For Form 8889 - Health Savings Accounts Hsas - 2007 Page 6

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