Form
 
8959
 
Department of the Treasury  
Internal Revenue Service 
Additional Medicare Tax
a
 
If any line does not apply to you, leave it blank. See separate instructions. 
 
a
 
Attach to Form 1040, 1040NR, 1040-PR, or 1040-SS.
 
 
a
 
OMB No. 1545-0074
20
13
Attachment   
Sequence No. 
71
Name(s) shown on Form 1040
Your social security number
Part I 
Additional Medicare Tax on Medicare Wages
1 
Medicare wages and tips from Form W-2, box 5. If you have 
more than one Form W-2, enter the total of the amounts 
from box 5 
................
1
2 
Unreported tips from Form 4137, line 6 
.......
2
3 
Wages from Form 8919, line 6 
..........
3 
4 
Add lines 1 through 3
............. 
4 
5 
Enter the following amount for your filing status:
Married filing jointly
..........
$250,000
Married filing separately
........
$125,000
Single, Head of household, or Qualifying widow(er)
 $200,000
5 
6 
Subtract line 5 from line 4. If the result is zero or less, enter -0- 
.......... 
6 
7 
Additional Medicare Tax on Medicare wages. Multiply line 6 by 0.9% (.009). Enter here and 
go to Part II 
...........................
7 
Part II 
Additional Medicare Tax on Self-Employment Income
8 
Self-employment income from Schedule SE  (Form 1040), 
Section A, line 4, or Section B, line 6. If you had a loss, enter 
-0- (Form 1040-PR and Form 1040-SS filers, see instructions.) 
8 
9
Enter the following amount for your filing status:
Married filing jointly
..........
$250,000
Married filing separately
........
$125,000
Single, Head of household, or Qualifying widow(er)
 $200,000
9
10 
Enter the amount from line 4 
..........
10 
11 
Subtract line 10 from line 9. If zero or less, enter -0-  .    .    .
11 
12 
Subtract line 11 from line 8. If the result is zero or less, enter -0- 
..........
12 
13 
Additional Medicare Tax on self-employment income. Multiply line 12 by 0.9% (.009). Enter 
here and go to Part III 
........................
13 
Part III 
Additional Medicare Tax on Railroad Retirement Tax Act (RRTA) Compensation
14
Railroad retirement (RRTA) compensation and tips from 
Form(s) W-2, box 14 (see instructions)
....... 
14 
15
Enter the following amount for your filing status:
Married filing jointly
..........
$250,000
Married filing separately
........
$125,000
Single, Head of household, or Qualifying widow(er)
 $200,000
15
16 
Subtract line 15 from line 14. If zero or less, enter -0- 
.............
16 
17 
Additional Medicare Tax on railroad retirement (RRTA) compensation. Multiply line 16 by 
0.9% (.009). Enter here and go to Part IV 
.................
17 
Part IV 
Total Additional Medicare Tax
18 
Add lines 7, 13, and 17. Also include this amount on Form 1040, line 60, (Form 1040NR, 
1040-PR, and 1040-SS filers, see instructions) and go to Part V 
........
18 
Part V 
Withholding Reconciliation
19 
Medicare tax withheld from Form W-2, box 6. If you have 
more than one Form W-2, enter the total of the amounts 
from box 6 
................
19
20
Enter the amount from line 1 
..........
20
21
Multiply line 20 by 1.45% (.0145). This is your regular 
Medicare tax withholding on Medicare wages 
.....
21
22
Subtract line 21 from line 19. This is your Additional Medicare Tax withholding on Medicare 
wages
.............................
22
23
Additional Medicare Tax withholding on railroad retirement (RRTA) compensation from Form 
W-2, box 14  (see instructions)
.....................
23
24
Total Additional Medicare Tax withholding. 
Add lines 22 and 23. Also include this 
 
amount with federal income tax withholding on Form 1040, line 62 (Form 1040NR, 1040-PR, 
and 1040-SS filers, see instructions) 
...................
24
For Paperwork Reduction Act Notice, see your tax return instructions. 
Cat. No. 59475X
Form 
8959 
(2013) 
Information about Form 8959 and its instructions is at www.irs.gov/form8959.
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