Instructions For Form 8889 (2015) Page 5
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6Employer 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 2015 for tax year 2014 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
2.
3. Subtract line 2 from line 1 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
3.
4. Enter employer contributions made in 2016 for tax year 2015 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
4.
5. Employer contributions for 2015. Add lines 3 and 4. Enter here and on Form 8889, line 9 . . . . . . . . . . . . . . . .
5.
2. You were not enrolled in
income, is not deductible, and reduces
HSA than is allowable, you may have to
Medicare for the month.
the amount that can be contributed to
pay an additional tax on the excess
your HSA. This distribution cannot be
contributions. Figure the excess
Enter the result on line 7.
made from an ongoing SEP IRA or
contributions using the following
SIMPLE IRA. For this purpose, a SEP
instructions. See Form 5329, Additional
If items (1) and (2) apply to all
IRA or SIMPLE IRA is ongoing if an
Taxes on Qualified Plans (Including
months during 2015, enter
TIP
employer contribution is made for the
IRAs) and Other Tax-Favored Accounts,
$1,000 on line 7.
plan year ending with or within your tax
to figure the additional tax.
Additional Contribution Amount
year in which the distribution would be
made.
Excess Contributions You Make
Worksheet
The maximum amount that can be
To figure your excess contributions
1. $1,000 × number of months
excluded from income is based on your
(including those made on your behalf),
eligible . . . . . . . . . . . . . . . . .
age at the end of the year and your
subtract your deductible contributions
2. Divide line 1 by 12. Enter
HDHP coverage (self-only or family) at
(line 13) from your actual contributions
here and on line 7 . . . . . . . .
the time of the distribution. You can
(line 2). However, you can withdraw
make only one qualified HSA funding
some or all of your excess contributions
distribution during your lifetime.
for 2015 and they will be treated as if
Example. At the end of 2015, you
However, if you make the distribution
they had not been contributed if:
were age 55 and married. You had
during a month when you have self-only
You make the withdrawal by the due
family coverage under an HDHP from
HDHP coverage, you can make another
date, including extensions, of your 2015
January 1 through June 30, 2015 (6
qualified HSA funding distribution in a
tax return (but see the
Note
under
months). You were not enrolled in
later month in that tax year if you
Excess Employer Contributions, later),
Medicare in 2015. You would enter an
change to family HDHP coverage.
You do not claim a deduction for the
additional contribution amount of $500
A qualified HSA funding distribution
amount of the withdrawn contributions,
on line 7 ($1,000 × 6 ÷ 12).
made during your tax year reduces the
and
Line 9
amount that can be contributed from
You also withdraw any income
other sources (including employer
earned on the withdrawn contributions
Employer Contributions
contributions) to your HSA. See the
and include the earnings in “Other
Employer contributions (including
discussions under
Line 13
for the
income” on your tax return for the year
contributions through a cafeteria plan)
treatment of excess contributions.
you withdraw the contributions and
include any amount an employer
earnings.
See Pub. 969 for more information.
contributes to any HSA for you for 2015.
These contributions should be shown in
Testing period. You must remain
Excess Employer Contributions
box 12 of Form W-2 with code W. If
an eligible individual during the testing
Excess employer contributions are the
either of the following apply, complete
period. The testing period begins with
excess, if any, of your employer's
the
Employer Contribution
Worksheet.
the month in which the qualified HSA
contributions over your limitation on
Employer contributions for 2014 are
funding distribution is contributed to the
line 8. If you made a qualified HSA
included in the amount reported in
HSA and ends on the last day of the
funding distribution (line 10) during the
box 12 of Form W-2 with code W.
12th month following that month. For
tax year, reduce your limitation (line 8)
Employer contributions for 2015 are
example, if the distribution is contributed
by that distribution before you determine
made in 2016.
on June 16, 2015, the testing period
whether you have excess employer
If your employer made excess
ends on June 30, 2016. If you fail to
contributions. If the excess was not
contributions, you may have to report
remain an eligible individual during this
included in income on Form W-2, you
the excess as income. See
Excess
period, other than because of death or
must report it as “Other income” on your
Employer
Contributions, later.
becoming disabled, you will have to
tax return. However, you can withdraw
include the qualified HSA funding
Line 10
some or all of the excess employer
distribution in income in the year in
contributions for 2015 and they will be
Enter on line 10 any qualified HSA
which you fail to be an eligible
treated as if they had not been
funding distribution made during the
individual. This amount is also subject to
contributed if:
year. This is a distribution from your
a 10% additional tax. (See
Part
III.)
You make the withdrawal by the due
traditional IRA or Roth IRA to your HSA
Line 13
date, including extensions, of your 2015
in a direct trustee-to-trustee transfer.
tax return (but see the following Note),
This distribution is not included in your
If you or someone on your behalf (or
your employer) contributed more to your
Form 8889 (2015)
-5-
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