Form 8889, Health Savings Account (HSA) Completed Form Examples and Samples

Explore clear, filled-out examples of IRS Form 8889 for Health Savings Accounts (HSA). See how to correctly calculate your deduction, report distributions, and file for self-only or family coverage.
Form 8889, Health Savings Account (HSA) has a basic Form Complexity Index of 35/100 — Instafill’s AI completes it in under a minute.
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Completed Form 8889 for an individual with self-only Health Savings Account (HSA) coverage

Form 8889 Example for Self-Only HSA Coverage

How this form was filled:

This sample Form 8889 shows how an individual with self-only HSA coverage for all of 2025 calculates their HSA deduction in Part I and reports distributions in Part II. The example includes both personal and employer contributions and confirms that all distributions were used for qualified medical expenses, resulting in no additional tax.

Information used to fill out the document:

  • Filer's Name: Jane Smith
  • HSA Coverage Type: Self-only
  • Coverage Period: Full Year (2025)
  • HSA Contribution Limit (2025): $4,300
  • Personal HSA Contributions: $3,000
  • Employer HSA Contributions (from Form W-2): $1,000
  • Total HSA Contributions: $4,000
  • HSA Deduction (Line 13): $3,000
  • Total Distributions from HSA (Line 14a): $1,500
  • Qualified Medical Expenses (Line 15): $1,500
  • Taxable HSA Distributions (Line 16): $0
  • Additional Tax on Distributions (Line 17b): $0

What this filled form sample shows:

  • Correctly calculates the **HSA deduction** in Part I based on personal contributions.
  • Reports total **HSA distributions** and verifies they were used for qualified medical expenses in Part II.
  • Demonstrates a common use case for an individual with **self-only coverage** for the full tax year.
  • Confirms that no additional income tax or penalties are due on the HSA distributions.

Form specifications and details:

Form: Form 8889
Title: Health Savings Accounts (HSAs)
Tax Year: 2025
Use Case: Individual with full-year, self-only HSA coverage, making contributions and taking qualified distributions.
Categories: HSA forms, health savings account forms, health savings forms, health forms, savings account forms
Created: February 25, 2026 06:01 PM
Completed Form 8889 for an individual with self-only Health Savings Account (HSA) coverage