Instructions For Form 8889 - Health Savings Accounts (Hsas) - 2004 Page 2

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You can also have coverage
You engaged in any transaction
Figuring Your HSA
(either through insurance or
prohibited by section 4975 with
Deduction
otherwise) for:
respect to any of your HSAs, at any
The amount you may deduct for HSA
Accidents,
time in 2004. Your account ceases to
contributions is limited by the
Disability,
be an HSA as of January 1, 2004,
applicable portion of the HDHP’s
Dental care,
and you must include the fair market
annual deductible (line 3) reduced by
Vision care, or
value of all assets in the account as
any contributions to your Archer
Long-term care.
of January 1, 2004, on line 12a.
MSAs (line 4) and any employer
For information on prescription
You used any portion of any of
contributions (line 9). If you were age
drug plans, see Pub. 969.
your HSAs as security for a loan at
55 or older at the end of 2004, you
any time in 2004. You must include
can increase the contribution limit to
Disabled
the fair market value of the assets
your HSA by up to $500
An individual generally is considered
used as security for the loan as
(line 3 or line 7 depending on your
disabled if he or she is unable to
income on Form 1040, line 21.
type of coverage and marital status).
engage in any substantial gainful
activity due to a physical or mental
You can make deductible
Any deemed distribution will not be
impairment which can be expected to
contributions to your HSA even if your
treated as used to pay qualified
result in death or to continue
employer made contributions.
medical expenses. Generally, these
indefinitely.
However, if you (or someone on your
distributions will be subject to the
behalf) made contributions in addition
additional 10% tax.
Death of Account Beneficiary
to any employer contributions, you
If the account beneficiary’s surviving
may have to pay an additional tax.
Rollovers
spouse is the designated beneficiary,
See Excess Contributions You Make
A rollover is a tax-free distribution
the HSA is treated as if the surviving
that begins on page 4.
(withdrawal) of assets from one HSA
spouse were the account beneficiary.
You cannot deduct any
or Archer MSA that is reinvested in
The surviving spouse completes
contributions you made after you
Form 8889 as though the HSA
another HSA. Generally, you must
were enrolled in Medicare. Also, you
belonged to him or her.
complete the rollover within 60 days
cannot deduct contributions if you can
after you received the distribution.
If the designated beneficiary is not
be claimed as a dependent on
You may make only one rollover
the account beneficiary’s surviving
someone else’s 2004 tax return.
contribution to an HSA during a
spouse, or there is no designated
1-year period. See Pub. 590,
beneficiary, the account ceases to be
How To Complete Part I
Individual Retirement Arrangements
an HSA as of the date of death. The
Complete lines 1 through 11 as
(IRAs), for more details and additional
beneficiary completes Form 8889 as
instructed on the form. However, if
requirements regarding rollovers.
follows.
filing jointly, and both you and your
Enter “Death of HSA account
Note. If you instruct the trustee of
spouse each have separate HSAs
beneficiary” across the top of Form
your HSA to transfer funds directly to
and an HDHP with family coverage,
8889.
complete a separate Form 8889 for
the trustee of another HSA, the
Enter the name(s) shown on your
each spouse as follows.
transfer is not considered a rollover.
tax return and your SSN in the
If either spouse has an HDHP with
There is no limit on the number of
spaces provided at the top of the form
family coverage, you both are treated
these transfers. Do not include the
and skip Part I.
as having only the family coverage
amount transferred in income, deduct
On line 12a, enter the fair market
plan. Disregard any plans with
it as a contribution, or include it as a
value of the HSA as of the date of
self-only coverage.
distribution on line 12a.
death.
If both spouses have HDHPs with
On line 13, for a beneficiary other
family coverage, you both are treated
than the estate, enter qualified
as having only the family coverage
medical expenses incurred by the
Specific Instructions
plan with the lowest annual
account beneficiary before the date of
deductible.
death that you paid within 1 year after
Name and social security number
the date of death.
Combine the amounts on line 11 of
(SSN). Enter your name(s) as shown
Complete the rest of Part II.
both Forms 8889 and enter this
on your tax return and the SSN of the
amount on Form 1040, line 28. Be
If the account beneficiary’s estate
HSA beneficiary. If married filing
sure to attach both Forms 8889 to
is the beneficiary, the value of the
jointly and both you and your spouse
your tax return.
HSA as of the date of death is
have HSAs, complete a separate
included on the account beneficiary’s
Form 8889 for each of you.
Line 1
final income tax return. Complete
Form 8889 as described above,
If you were covered by a self-only
Part I—HSA
except you should complete Part I, if
HDHP and a family HDHP at different
applicable.
times during the year, check the box
Contributions and
for the plan that was in effect for a
The distribution is not subject to
longer period. If you were covered by
Deductions
the additional 10% tax. Report any
both a self-only HDHP and a family
earnings on the account after the
Use Part I to figure:
HDHP at the same time, you are
date of death as income on your tax
Your HSA deduction,
treated as having family coverage
return.
Any excess contributions you made
during that period.
Deemed Distributions From
(or those made on your behalf), and
Line 2
HSAs
Any excess contributions made by
an employer (see Excess Employer
The following situations result in
Do not include employer contributions
deemed distributions from your HSA.
Contributions on page 5).
or amounts rolled over from another
-2-

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