Form 8889, Health Savings Accounts Instructions
This form contains 27 fields organized into 5 sections. Below is a complete list of every field, its type, and what information is expected.
| Field Name | Type | Description |
|---|---|---|
| HDHP Coverage Type | ||
| Self-only | Checkbox |
Check this box if your high-deductible health plan (HDHP) coverage during 2023 was for self-only.
|
| Family | Checkbox |
Check this box if your high-deductible health plan (HDHP) coverage during 2023 was for a family.
|
| HSA Contributions and Deduction | ||
| HSA Contributions | Number |
Enter the total HSA contributions made for 2023, including those made on your behalf, excluding employer contributions, cafeteria plan contributions, or rollovers.
|
| Contribution Limit if Under 55 | Number |
Enter the maximum contribution amount if you were under age 55 at the end of 2023 and had qualifying coverage.
|
| Archer MSA Contributions | Number |
Enter the combined amount you and your employer contributed to your Archer MSAs for 2023.
|
| Subtracted Contribution Limit | Number |
Enter the result of subtracting the Archer MSA contributions from the contribution limit.
|
| Adjusted Contribution Limit | Number |
Enter the amount from line 5, adjusted if you and your spouse each have separate HSAs and family coverage.
|
| Additional Contribution Amount | Number |
Enter your additional contribution amount if you were age 55 or older at the end of 2023, married, and had family coverage under an HDHP.
|
| Total Contribution Limit | Number |
Enter the sum of the amounts from line 6 and line 7.
|
| Employer HSA Contributions | Number |
Enter the total employer contributions made to your HSAs for 2023.
|
| Qualified HSA Funding Distributions | Number |
Enter the total qualified HSA funding distributions received.
|
| Total Employer & Funding Contributions | Number |
Enter the sum of the employer contributions and qualified HSA funding distributions.
|
| Net Contributions After Deductions | Number |
Enter the result of subtracting the total employer and funding contributions from the total contribution limit.
|
| HSA Deduction | Number |
Enter the smaller of the amount from line 2 (HSA contributions you made) or line 12 (Net Contributions After Deductions).
|
| HSA Distributions | ||
| Total Distributions | Number |
Enter the total amount of distributions received in 2023 from all Health Savings Accounts.
|
| Rollover or Excess Distributions | Number |
Enter the amount of distributions included in line 14a that were rolled over to another HSA or were excess contributions withdrawn by the due date of your return.
|
| Net Distributions After Rollover | Number |
Enter the result of subtracting the amount on line 14b from the amount on line 14a.
|
| Qualified Medical Expenses | Number |
Enter the total amount of qualified medical expenses paid using Health Savings Account distributions.
|
| Taxable HSA Distributions | Number |
Enter the result of subtracting the amount on line 15 from the amount on line 14c; if the result is zero or less, enter -0-.
|
| Exceptions to Additional 20% Tax | Checkbox |
Check this box if any of the distributions reported on line 16 meet the criteria for exceptions to the additional 20% tax.
|
| Additional 20% Tax | Number |
Enter 20% (0.20) of the distributions included on line 16 that are subject to the additional 20% tax. Fill only if 'Exceptions to Additional 20% Tax' is 'No'.
Depends on:
Exceptions to Additional 20% Tax
|
| Income and Additional Tax for Failure To Maintain HDHP Coverage | ||
| 18 18 | Text |
Enter the amount for line 18.
|
| 19 19 Qualified HSA funding distribution | Text |
Enter the amount for line 19, which is the Qualified HSA funding distribution.
|
| 20 20 Total income. Add lines 18 and 19. Include this amount on Schedule 1 (Form 1040), Part I, line 8f | Text |
Enter the total income by adding lines 18 and 19. Include this amount on Schedule 1 (Form 1040), Part I, line 8f.
|
| Additional tax. Multiply line 20 by 10% (0.10). Include this amount in the total on Schedule 2 (Form 1040), Part II, line 17d. 21 21 | Text |
Calculate the additional tax by multiplying the amount on line 20 by 10% (0.10). Include this amount in the total on Schedule 2 (Form 1040), Part II, line 17d.
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| Taxpayer Information | ||
| Taxpayer Name | Text |
Provide the name(s) as shown on your Form 1040, 1040-SR, or 1040-NR.
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| HSA Beneficiary Social Security Number | Text |
Enter the Social Security Number of the HSA beneficiary.
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