Instructions For Form 8889 - 2016 (Page 6 of 6) in pdf

amended return with “Filed pursuant to

check the box on line 17a. Enter on

reimbursed by insurance or other

section 301.9100-2” written at the top.

line 17b only 20% (0.20) of any amount

coverage and that you incurred after the

Include an explanation of the

included on line 16 that does not meet

HSA was established. Do not include

withdrawal. Make all necessary

any of the exceptions.

the distribution of an excess contribution

changes on the amended return (for

Example 1. You turned age 63 in

taken out after the due date, including

example, if you reported the

2016 and received a distribution from an

extensions, of your return even if used

contributions as excess contributions on

HSA that is included in income. Do not

for qualified medical expenses.

your original return, include an amended

check the box on line 17a because you

Form 5329 reflecting that the withdrawn

In general, include on line 15

(the account beneficiary) did not meet

contributions are no longer treated as

distributions from all HSAs in 2016 that

the age exception for the distribution.

having been contributed).

were used for the qualified medical

Enter 20% of the amount from line 16 on

expenses (see

Qualified Medical

line 17b.

Expenses, earlier) of:

Deducting an Excess Contribution

Example 2. You turned age 65 in

in a Later Year

1. You and your spouse.

2016. You received distributions that are

2. All dependents you claim on your

included in income both before and after

You may be able to deduct excess

tax return.

you turned age 65. Check the box on

contributions for previous years that are

line 17a because the additional 20% tax

still in your HSA. The excess

3. Any person you could have

does not apply to the distributions made

contributions you can deduct in the

claimed as a dependent on your return

after the date you turned age 65.

current year is the lesser of the following

except that:

However, the additional 20% tax does

two amounts.

a. The person filed a joint return.

apply to the distributions made on or

Your maximum HSA contribution limit

b. The person had gross income of

before the date you turned age 65.

for the year minus any amounts

$4,050 or more.

Enter on line 17b, 20% of the amount of

contributed to your HSA for the year.

these distributions included in line 16.

The total excess contributions in your

c. You, or your spouse if filing

HSA at the beginning of the year.

jointly, could be claimed as a dependent

Part III—Income and

on someone else's return.

Any excess contribution remaining at

Additional Tax for Failure

For this purpose, a child of

the end of the tax year is subject to the

to Maintain HDHP

parents that are divorced,

additional tax. See Form 5329.

TIP

Coverage

separated, or living apart for the

Part II—HSA Distributions

last 6 months of the calendar year is

Use Part III to figure any income and

treated as the dependent of both

additional tax that must be reported on

Line 14a

parents whether or not the custodial

Form 1040 or Form 1040NR for failure

parent releases the claim to the child's

Enter the total distributions you received

to be an eligible individual during the

exemption.

in 2016 from all HSAs. Your total

testing period for:

distributions include amounts paid with

Last-month rule (see

Last-month

rule,

You cannot take a deduction on

a debit card that restricts payments to

earlier), or

Schedule A (Form 1040) for any

health care and amounts withdrawn by

A qualified HSA funding distribution

amount you include on line 15.

other individuals that you have

(see the

Instructions for line

10, earlier).

CAUTION

designated. These amounts should be

Lines 17a and 17b

shown in box 1 of Form 1099-SA.

See the discussions indicated to

Additional 20% Tax

determine the testing period for these

Line 14b

items. Include the amount in income in

HSA distributions included in income

Include on line 14b any distributions you

the year in which you fail to be an

(line 16) are subject to an additional

received in 2016 that qualified as a

eligible individual.

20% tax unless one of the following

rollover contribution to another HSA.

exceptions applies.

Line 18

See Rollovers, earlier. Also include any

excess contributions (and the earnings

You can use the

Line 3 Limitation Chart

Exceptions to the Additional 20%

on those excess contributions) included

and Worksheet

for the year the

on line 14a that were withdrawn by the

Tax

contribution was made to determine the

due date, including extensions, of your

contribution you could have made if the

The additional 20% tax does not apply

return. See the instructions for line 13,

last-month rule did not apply. Enter on

to distributions made after the account

earlier.

line 18 the excess of the amount

beneficiary:

contributed over the redetermined

Line 15

Dies,

amount. Examples of this computation

Becomes disabled (see Disabled,

Only include on line 15

are in Pub. 969.

earlier), or

distributions from your HSA that

Turns age 65.

Line 19

were used to pay you for

CAUTION

Enter the total of any qualified HSA

qualified medical expenses (see

If any of the exceptions apply to any

funding distribution (see Line 10).

Qualified Medical

Expenses, earlier) not

of the distributions included on line 16,

-6-

Form 8889 (2016)

Instructions For Form 8889 - 2016 Page 6

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