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. 1545-00742013

Attachment   Sequence No. 71

Name(s) shown on Form 1040Your 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) $200,0005 

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 

9Enter 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) $200,0009

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

14Railroad retirement (RRTA) compensation and tips from 

Form(s) W-2, box 14 (see instructions)....... 14 

15Enter 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) $200,00015

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

20Enter the amount from line 1 ..........20

21Multiply line 20 by 1.45% (.0145). This is your regular 

Medicare tax withholding on Medicare wages .....21

22Subtract line 21 from line 19. This is your Additional Medicare Tax withholding on Medicare 

wages.............................22

23Additional Medicare Tax withholding on railroad retirement (RRTA) compensation from Form 

W-2, box 14  (see instructions).....................23

24Total 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. 59475XForm 8959 (2013) 

Information about Form 8959 and its instructions is at www.irs.gov/form8959.

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