Form 8889 - Health Savings Accounts (Hsas) - 2017 Page 2

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Form 8889 (2017)
Page
Part III
Income and Additional Tax for Failure To Maintain HDHP Coverage. See the instructions before
completing this part. If you are filing jointly and both you and your spouse each have separate HSAs,
complete a separate Part III for each spouse.
18
18
Last-month rule .
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19
Qualified HSA funding distribution .
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19
20
Total income. Add lines 18 and 19. Include this amount on Form 1040, line 21, or Form
1040NR, line 21. On the dotted line next to Form 1040, line 21, or Form 1040NR, line 21, enter
“HSA” and the amount
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20
21
Additional tax. Multiply line 20 by 10% (0.10). Include this amount in the total on Form 1040,
line 62, or Form 1040NR, line 60. Check box c on Form 1040, line 62, or box b on Form 1040NR,
line 60. Enter “HDHP” and the amount on the line next to the box
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8889
Form
(2017)

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