OMB No. 1545-0074

Form 8889 Health Savings Accounts (HSAs)

Department of the Treasury

Internal Revenue Service © Attach to Form 1040 or Form 1040NR.

Name(s) shown on Form 1040 or Form 1040NR

Cat. No. 37621P Form 8889 (2008)

HSA contributions you made for 2008 (or those made on your behalf), including direct

deposits of economic stimulus payments and those made from January 1, 2009, through

April 15, 2009, that were for 2008. Do not include employer contributions, contributions

through a cafeteria plan, or rollovers (see page 4 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.

14a Total distributions you received in 2008 from all HSAs (see page 6 of the instructions)

Unreimbursed qualified medical expenses (see page 6 of the instructions)

c

17a

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

Add lines 6 and 7 

Subtract line 11 from line 8. If zero or less, enter -0- 

HSA deduction. Enter the smaller of line 2 or line 12 here and on Form 1040, line 25, or Form 

1040NR, line 25

6

7

8

13

14a

14b

Attachment

Sequence No. 53

b

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

4

5

12

© See separate instructions.

If any of the distributions included on line 16 meet any of the Exceptions to the Additional 

10% Tax (see page 6 of the instructions), check here ©

Additional 10% tax (see page 6 of the instructions). Enter 10% (.10) of the distributions included 

on line 16 that are subject to the additional 10% tax. Also include this amount in the total on

Form 1040, line 61, or Form 1040NR, line 57. On the dotted line next to Form 1040, line 61, or 

Form 1040NR, line 57, enter “HSA” and the amount

HSA Contributions and Deduction. See page 3 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.

Distributions included on line 14a that you rolled over to another HSA. Also include any portion 

of a direct deposit of an economic stimulus payment and excess contributions (and the earnings 

on those excess contributions) included on line 14a that were withdrawn by the due date of your 

return (see page 6 of the instructions) 

Subtract line 14b from line 14a 14c

15 15

16

b

17b

Social security number of HSA

beneficiary. If both spouses have

HSAs, see page 2 of the instructions ©

3

Part I

1

2

3

6

If you were age 55 or older at the end of 2008, married, and you or your spouse had family

coverage under an HDHP at any time during 2008, enter your additional contribution amount

(see page 5 of the instructions) 7

Caution: If line 2 is more than line 13, you may have to pay an additional tax (see page 5 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 (HDHP) during 

2008 (see page 4 of the instructions) © Self-only Family

If you were under age 55 at the end of 2008, and on the first day of every month during 2008, you

were, or were considered, an eligible individual with the same coverage, enter $2,900 ($5,800 for

family coverage). All others, see page 4 of the instructions for the amount to enter 

Enter the amount you and your employer contributed to your Archer MSAs for 2008 from Form 

8853, lines 3 and 4. If you or your spouse had family coverage under an HDHP at any time during 

2008, also include any amount contributed to your spouse’s Archer MSAs

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

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 2008, see the instructions on page 4 for the 

amount to enter

2

5

4

Employer contributions made to your HSAs for 2008 

8

9

12

13

9

Part II

Qualified HSA funding distributions

11 Add lines 9 and 10

10 10

11

2008
Form 8889 (2008)

Income and Additional Tax for Failure To Maintain HDHP Coverage. See page 6 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 III for each spouse.

18 Qualified HSA distribution

Last-month rule

21

Qualified HSA funding distribution 20

18

Total income. Add lines 18, 19, and 20. 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

Additional tax. Multiply line 21 by 10% (.10). Include this amount in the total on Form 1040, line 

61, or Form 1040NR, line 57. On the dotted line next to Form 1040, line 61, or Form 1040NR,

line 57, enter “HDHP” and the amount

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Part III

Form 8889 (2008) Page 2

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