Instructions For Form 8889 - 2016 Page 5

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Employer Contribution Worksheet
Keep for Your Records
1. Enter the employer contributions reported in box 12 of Form W-2, with code W . . . . . . . . . . . . . . . . . . . . . . . . . .
1.
2. Enter employer contributions made in 2016 for tax year 2015 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
2.
3. Subtract line 2 from line 1 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
3.
4. Enter employer contributions made in 2017 for tax year 2016 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
4.
5. Employer contributions for 2016. Add lines 3 and 4. Enter here and on Form 8889, line 9 . . . . . . . . . . . . . . . .
5.
The maximum amount that can be
subtract your deductible contributions
Additional Contribution Amount
excluded from income is based on your
(line 13) from your actual contributions
Worksheet
age at the end of the year and your
(line 2). However, you can withdraw
HDHP coverage (self-only or family) at
some or all of your excess contributions
1. $1,000 × number of months
the time of the distribution. You can
for 2016 and they will be treated as if
eligible . . . . . . . . . . . . . . . . .
make only one qualified HSA funding
they had not been contributed if:
2. Divide line 1 by 12. Enter
distribution during your lifetime.
You make the withdrawal by the due
here and on line 7 . . . . . . . .
However, if you make the distribution
date, including extensions, of your 2016
during a month when you have self-only
tax return (but see the
Note
under
HDHP coverage, you can make another
Excess Employer Contributions, later),
Example. At the end of 2016, you
qualified HSA funding distribution in a
You do not claim a deduction for the
were age 55 and married. You had
later month in that tax year if you
amount of the withdrawn contributions,
family coverage under an HDHP from
change to family HDHP coverage.
and
January 1 through June 30, 2016 (6
You also withdraw any income
months). You were not enrolled in
A qualified HSA funding distribution
earned on the withdrawn contributions
Medicare in 2016. You would enter an
made during your tax year reduces the
and include the earnings in “Other
additional contribution amount of $500
amount that can be contributed from
income” on your tax return for the year
on line 7 ($1,000 × 6 ÷ 12).
other sources (including employer
you withdraw the contributions and
contributions) to your HSA. See the
Line 9
earnings.
discussions under
Line 13
for the
Employer Contributions
treatment of excess contributions.
Excess Employer Contributions
Employer contributions (including
See Pub. 969 for more information.
Excess employer contributions are the
contributions through a cafeteria plan)
excess, if any, of your employer's
Testing period. You must remain
include any amount an employer
contributions over your limitation on
an eligible individual during the testing
contributes to any HSA for you for 2016.
line 8. If you made a qualified HSA
period. The testing period begins with
These contributions should be shown in
funding distribution (line 10) during the
the month in which the qualified HSA
box 12 of Form W-2 with code W. If
tax year, reduce your limitation (line 8)
funding distribution is contributed to the
either of the following apply, complete
by that distribution before you determine
HSA and ends on the last day of the
the
Employer Contribution
Worksheet.
whether you have excess employer
12th month following that month. For
Employer contributions for 2015 are
contributions. If the excess was not
example, if the distribution is contributed
included in the amount reported in
included in income on Form W-2, you
on June 16, 2016, the testing period
box 12 of Form W-2 with code W.
must report it as “Other income” on your
ends on June 30, 2017. If you fail to
Employer contributions for 2016 are
tax return. However, you can withdraw
remain an eligible individual during this
made in 2017.
some or all of the excess employer
period, other than because of death or
If your employer made excess
contributions for 2016 and they will be
becoming disabled, you will have to
contributions, you may have to report
treated as if they had not been
include the qualified HSA funding
the excess as income. See
Excess
contributed if:
distribution in income in the year in
Employer
Contributions, later.
You make the withdrawal by the due
which you fail to be an eligible
Line 10
date, including extensions, of your 2016
individual. This amount is also subject to
tax return (but see the following Note),
Enter on line 10 any qualified HSA
a 10% additional tax. (See
Part
III.)
You do not claim an exclusion from
funding distribution made during the
Line 13
income for the amount of the withdrawn
year. This is a distribution from your
contributions, and
If you or someone on your behalf (or
traditional IRA or Roth IRA to your HSA
You also withdraw any income
your employer) contributed more to your
in a direct trustee-to-trustee transfer.
earned on the withdrawn contributions
HSA than is allowable, you may have to
This distribution is not included in your
and include the earnings in “Other
pay an additional tax on the excess
income, is not deductible, and reduces
income” on your tax return for the year
contributions. Figure the excess
the amount that can be contributed to
you withdraw the contributions and
contributions using the following
your HSA. This distribution cannot be
earnings.
instructions. See Form 5329, Additional
made from an ongoing SEP IRA or
Taxes on Qualified Plans (Including
SIMPLE IRA. For this purpose, a SEP
Note. If you timely filed your return
IRAs) and Other Tax-Favored Accounts,
IRA or SIMPLE IRA is ongoing if an
without withdrawing the excess
to figure the additional tax.
employer contribution is made for the
contributions, you can still make the
plan year ending with or within your tax
withdrawal no later than 6 months after
year in which the distribution would be
Excess Contributions You Make
the due date of your tax return,
made.
To figure your excess contributions
excluding extensions. If you do, file an
(including those made on your behalf),
Form 8889 (2016)
-5-

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