Instructions For Form 8889 - Health Savings Accounts (Hsas)

they will be treated as if they had not

These amounts should be shown in

account beneficiary) did not meet the

been contributed if:

box 1 of Form 1099-SA.

age exception for the distribution. You

•

You make the withdrawal by the

enter 10% of the amount from line 14

Line 12b

due date, including extensions, of

on line 15b.

Include on line 12b any distributions

your 2004 tax return,

Example 2. You turned age 65

•

you received in 2004 that qualified as

You do not claim a deduction for

during the year. You received

a rollover contribution to another

the amount of the withdrawn

distributions that are included in

HSA. See Rollovers on page 2. Also

contributions, and

income both before and after you

•

include any excess contributions (and

You also withdraw any income

turned age 65. You check the box on

the earnings on those excess

earned on the withdrawn

line 15a because the additional 10%

contributions) included on line 12a

contributions and include the

tax does not apply to the distributions

that were withdrawn by the due date,

earnings in “Other income” on your

made after the date you turned age

including extensions, of your return.

tax return for the year you withdraw

65. However, the additional 10% tax

See the instructions for line 11 on

the contributions and earnings.

does apply to the distributions made

page 4.

on or before the date you turned age

Excess Employer Contributions

65. You enter on line 15b, 10% of the

Line 13

Excess employer contributions are

amount of these distributions included

the excess, if any, of your employer’s

in line 14.

Only include on line 13

contributions over your limitation on

distributions from your HSA

line 8. If the excess was not included

that were used to pay or

in income on Form W-2, you must

Paperwork Reduction Act Notice.

CAUTION

reimburse qualified medical expenses

report it as “Other income” on your

We ask for the information on this

(see page 1) you incurred on or after

tax return. However, you may

form to carry out the Internal

the first day of the first month you

withdraw some or all of the excess

Revenue laws of the United States.

became an eligible individual (see

employer contributions for 2004 and

You are required to give us the

page 1).

they will be treated as if they had not

information. We need it to ensure that

been contributed if:

you are complying with these laws

In general, include on line 13

•

You make the withdrawal by the

and to allow us to figure and collect

distributions from all HSAs in 2004

due date, including extensions, of

the right amount of tax.

that were used for the qualified

your 2004 tax return,

medical expenses of the account

You are not required to provide the

•

You do not claim an exclusion from

beneficiary and his or her spouse or

information requested on a form that

income for the amount of the

dependents.

is subject to the Paperwork Reduction

withdrawn contributions, and

Act unless the form displays a valid

•

You cannot take a deduction

You also withdraw any income

OMB control number. Books or

on Schedule A (Form 1040)

earned on the withdrawn

records relating to a form or its

for any amount you include on

CAUTION

contributions and include the

instructions must be retained as long

line 13.

earnings in “Other income” on your

as their contents may become

tax return for the year you withdraw

Lines 15a and 15b

material in the administration of any

the contributions and earnings.

Internal Revenue law. Generally, tax

Additional 10% Tax

Note. If you timely filed your return

returns and return information are

without withdrawing the excess

confidential, as required by section

HSA distributions included in income

contributions, you can still make the

6103.

(line 14) are subject to an additional

withdrawal no later than 6 months

10% tax unless an exception applies.

The time needed to complete and

after the due date of your tax return,

If any of the following exceptions

file this form will vary depending on

excluding extensions. If you do, file

apply to any of the distributions

individual circumstances. The

an amended return with “Filed

included on line 14, check the box on

estimated average time is:

pursuant to section 301.9100-2”

line 15a. Enter on line 15b only 10%

written at the top. Include an

(.10) of any amount included on line

Recordkeeping . . . . . . . .

33 min.

explanation of the withdrawal. Make

14 that does not meet any of the

Learning about the law or

all necessary changes on the

exceptions.

the form . . . . . . . . . . . . .

19 min.

amended return (for example, if you

Exceptions to the Additional

reported the contributions as excess

Preparing the form . . . . .

1 hr., 9 min.

10% Tax

contributions on your original return,

Copying, assembling, and

include an amended Form 5329

The additional 10% tax does not

sending the form to the

reflecting that the withdrawn

apply to distributions made after the

IRS . . . . . . . . . . . . . . . . .

20 min.

contributions are no longer treated as

account beneficiary —

•

having been contributed).

Dies,

If you have comments concerning

•

Becomes disabled (see page 2), or

the accuracy of these time estimates

•

Part II—HSA

Turns age 65.

or suggestions for making this form

simpler, we would be happy to hear

Example 1. You turned age 63

Distributions

from you. See the Instructions for

during the year and received a

Form 1040.

distribution from an HSA that is

Line 12a

included in income. You do not check

Enter the total distributions you

the box on line 15a because you (the

received in 2004 from all HSAs.

-5-

Instructions For Form 8889 - Health Savings Accounts (Hsas) - 2004 Page 5

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