OMB No. 1545-1911

Form 8889 Health Savings Accounts (HSAs)

Department of the Treasury

Internal Revenue Service  Attach to Form 1040.

Name(s) shown on Form 1040

Cat. No. 37621P Form 8889 (2004)

HSA contributions you made for 2004 (or those made on your behalf), including those made

from January 1, 2005, through April 15, 2005, that were for 2004. Do not include employer

contributions or rollovers (see page 2 of the instructions)

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.

12a Total distributions you received in 2004 from all HSAs (see page 5 of the instructions)

Unreimbursed qualified medical expenses (see page 5 of the instructions)

c

15a

Taxable HSA distributions. Subtract line 13 from line 12c. If zero or less, enter -0-. Also, include

this amount in the total on Form 1040, line 21. On the dotted line next to line 21, enter “HSA”

and the amount 14

Add lines 6 and 7

Subtract line 9 from line 8. If zero or less, enter -0- 

HSA deduction. Enter the smaller of line 2 or line 10 here and on Form 1040, line 28

6

7

8

11

12a

12b

Attachment

Sequence No. 138

b

For Paperwork Reduction Act Notice, see page 5 of the instructions.

4

5

10

 See separate instructions.

If any of the distributions included on line 14 meet any of the Exceptions to the Additional

10% Tax (see page 5 of the instructions), check here 

Additional 10% tax (see page 5 of the instructions). Enter 10% (.10) of the distributions included

on line 14 that are subject to the additional 10% tax. Also include this amount in the total on

Form 1040, line 62. On the dotted line next to line 62, enter “HSA” and the amount

HSA Contributions and Deduction. See page 2 of 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 (see page 2 of the instructions).

Distributions included on line 12a that you rolled over to another HSA. Also include any excess

contributions (and the earnings on those excess contributions) included on line 12a that were

withdrawn by the due date of your return (see page 5 of the instructions)

Subtract line 12b from line 12a 12c

13 13

14

b

15b

Social security number of HSA

beneficiary. If both spouses have

HSAs, see page 2 of the instructions 

3

Part I

1

2

3

Part II

6

2004

If you were age 55 or older at the end of 2004, married, and you or your spouse had family

coverage under a high-deductible health plan at any time during 2004, enter the additional

contribution amount from the worksheet on page 4 of the instructions 7

Caution: If line 2 is more than line 11, you may have to pay an additional tax (see page 4 of the

instructions).

Before you begin: Complete Form 8853, Archer MSAs and Long-Term Care Insurance Contracts, if required.

Check the box to indicate your coverage under a high-deductible

health plan during 2004 (see page 2 of the instructions)  Self-only Family

If you were under age 55 at the end of 2004, and on the first day of every month during 2004, you

were an eligible individual with the same annual deductible and coverage, enter the smaller of:

● Your annual deductible (see page 3 of the instructions), or

● $2,600 ($5,150 for family coverage).

All others, enter the limit from the worksheet on page 3 of the instructions

Enter the amount you and your employer contributed to your Archer MSAs for 2004 from Form

8853, lines 3 and 4. If you or your spouse had family coverage under a high-deductible health

plan at any time during 2004, also include any amount contributed to your spouse’s Archer MSAs

Subtract line 4 from line 3. If zero or less, enter -0-

If you and your spouse each have separate HSAs and had family coverage under a

high-deductible health plan at any time during 2004, see the instructions on page 4 for the amount

to enter. All others, enter the amount from line 5

2

5

4

Employer contributions made to your HSAs for 2004

8

9

10

11

9