Form 8889 Department of the Treasury Internal Revenue Service a a Attach to Form 1040 or Form 1040NR. OMB No. 1545-0074 20 13 Attachment Sequence No. 53 Health Savings Accounts (HSAs) Name(s) shown on Form 1040 or Form 1040NR Social security number of HSA beneficiary. If both spouses have HSAs, see instructions a Before you begin: Complete Form 8853, Archer MSAs and Long-Term Care Insurance Contracts, if required. Part I HSA Contributions and Deduction. See the instructions before completing this part. If you are filing jointly and both you and your spouse each have separate HSAs, complete a separate Part I for each spouse. 1 Check the box to indicate your coverage under a high-deductible health plan (HDHP) during 2013 (see instructions) ........................ a Self-only Family 2 HSA contributions you made for 2013 (or those made on your behalf), including those made Do not contributions, contributions through a cafeteria plan, or rollovers (see instructions) ..... 2 3 If you were under age 55 at the end of 2013, and on the first day of every month during 2013, same All others, .... 3 4 Enter the amount you and your employer contributed to your Archer MSAs for 2013 from Form 8853, lines 1 and 2. If you or your spouse had family coverage under an HDHP at any time during 2013, also include any amount contributed to your spouse’s Archer MSAs ..... 4 5 Subtract line 4 from line 3. If zero or less, enter -0- ............... 5 6 Enter the amount from line 5. But if you and your spouse each have separate HSAs and had family coverage under an HDHP at any time during 2013, see the instructions for the amount to enter .............................. 6 7 If you were age 55 or older at the end of 2013, married, and you or your spouse had family coverage under an HDHP at any time during 2013, enter your additional contribution amount (see instructions) .......................... 7 8 Add lines 6 and 7 .......................... 8 9 Employer contributions made to your HSAs for 2013 .... 9 10 Qualified HSA funding distributions .......... 10 11 Add lines 9 and 10 .......................... 11 12 Subtract line 11 from line 8. If zero or less, enter -0- ............... 12 13 1040NR, line 25 ........................... 13 Caution: If line 2 is more than line 13, you may have to pay an additional tax (see instructions). Part II HSA Distributions. If you are filing jointly and both you and your spouse each have separate HSAs, complete a separate Part II for each spouse. 14a Total distributions you received in 2013 from all HSAs (see instructions) ........ 14a b Distributions included on line 14a that you rolled over to another HSA. Also include any excess contributions (and the earnings on those excess contributions) included on line 14a that were withdrawn by the due date of your return (see instructions) ............ 14b c Subtract line 14b from line 14a ...................... 14c 15 Unreimbursed qualified medical expenses (see instructions) ............ 15 16 Taxable HSA distributions. Subtract line 15 from line 14c. If zero or less, enter -0-. Also, include this amount in the total on Form 1040, line 21, or Form 1040NR, line 21. On the dotted line next to line 21, enter “HSA” and the amount ................ 16 17 a If any of the distributions included on line 16 meet any of the Exceptions to the Additional 20% Tax (see instructions), check here ................. a b Additional 20% tax line 60, or Form 1040NR, line 59. On the dotted line next to Form 1040, line 60, or Form 1040NR, line 59, enter “HSA” and the amount ................. 17b For Paperwork Reduction Act Notice, see your tax return instructions. Cat. No. 37621P Form 8889 (2013) (see instructions). Enter 20% (.20) of the distributions included on line 16 that are subject to the additional 20% tax. Also include this amount in the total on Form 1040, Information about Form 8889 and its separate instructions is available at www.irs.gov/form8889. from January 1, 2014, through April 15, 2014, that were for 2013. include employer you were, or were considered, an eligible individual with the coverage, enter $3,250 ($6,450 for family coverage). see the instructions for the amount to enter HSA deduction. smaller Enter the of line 2 or line 12 here and on Form 1040, line 25, or Form ----------------Page (0) Break---------------- Form 8889 (2013) Page 2 Part III Income and Additional Tax for Failure To Maintain HDHP Coverage. completing this part. If you are filing jointly and both you and your spouse each have separate HSAs, complete a separate Part III for each spouse. 18 18 19 Last-month rule ........................... 19 20 Qualified HSA funding distribution ..................... 20 21 Total income. Add lines 18 and 19. Include this amount on Form 1040, line 21, or Form 1040NR, line 21. On the dotted line next to Form 1040, line 21, or Form 1040NR, line 21, enter “HSA” and the amount ........................ 21 Additional tax. Multiply line 20 by 10% (.10). Include this amount in the total on Form 1040, line 60, or Form 1040NR, line 59. On the dotted line next to Form 1040, line 60, or Form 1040NR, line 59, enter “HDHP” and the amount ................... Form 8889 (2013) See the instructions before ----------------Page (1) Break----------------