Instructions For Form 8889 - 2016 Page 4
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6spouse in Step 2 from the amount
determined in Step 1.
Step 4. Determine any other
contribution limits that apply for the tax
year and add that amount to the result in
Step 3. Enter the total on line 6.
Example. In 2016, you are an
eligible individual and have family
HDHP coverage. In March you divorce
Line 3 Limitation Chart and Worksheet
and change your coverage as of April 1
to self-only. Neither you nor your
Before you begin: See the instructions for line 3, earlier.
ex-spouse qualify for the additional
Go through this chart for each month of 2016.
contribution amount. Your ex-spouse
(Keep for your records)
continued to have family HDHP
coverage and was an eligible individual
Start Here
for the entire year. The contribution limit
for the 3 months you both were
Were you enrolled in Medicare for the
Yes
considered to have family coverage is
month?
$1,687.50 ($6,750 × 3 ÷ 12). You and
No
your ex-spouse decide to divide the
family coverage contribution in the
following manner: 75% to your
Were you an eligible individual (see
ex-spouse and 25% to you. Your
Eligible Individual, earlier) on the rst
Enter -0- on the line
contribution limit for 9 months of
No
day of the month (see the line 3
below for the month.
self-only coverage is $2,512.50 ($3,350
instructions, earlier)?
× 9 ÷ 12). This amount is not divided
between you and your spouse.
Yes
Because you are covered under a
self-only policy on December 1, you will
show $3,350 on line 6 (the greater of
What type of coverage did your HDHP provide on the rst
either (a) $2,934.37 ($1,687.50 family
day of the month?
coverage + $2,512.50 self-only
coverage – $1,265.63 spousal
allocation) or (b) the maximum amount
Self-only coverage
Family coverage
that can be contributed ($3,350 for
self-only coverage). Your ex-spouse
Enter $6,750 on the line below for the
Enter $3,350 on the line below for the
would show $6,750 on line 6 (the
month. If, at the end of 2016, you were
month. If you were age 55 or older at the
unmarried and age 55 or older, enter
greater of either (a) $6,328.13
end of 2016, enter $4,350 for the month.
$7,750 for the month.
($1,687.50 family coverage for the 3
months prior to the divorce + $5,062.50
family coverage maintained after the
divorce – $421.87 spousal allocation) or
(b) the maximum amount that can be
Amount from
contributed ($6,750 for family
chart above
Month in 2016
coverage).
January
Line 7
Additional Contribution Amount
February
If, at the end of 2016, you were age 55
March
or older and married, use the
Additional
Contribution Amount
Worksheet, later, if
April
both of the following apply.
May
1. You or your spouse had family
coverage under an HDHP and were, or
June
were considered to be, an eligible
July
individual on the first day of the month.
2. You were not enrolled in
August
Medicare for the month.
September
Enter the result on line 7.
October
If items (1) and (2) apply to all
months during 2016, enter
November
TIP
$1,000 on line 7.
December
Total for all months
Limitation. Divide the total by 12. Enter here and on line 3
-4-
Form 8889 (2016)
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