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 (2007)

HSA contributions you made for 2007 (or those made on your behalf), including those made

from January 1, 2008, through April 15, 2008, that were for 2007. 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 2007 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 63, or Form 1040NR, line 58. On the dotted line next to Form 1040, line 63, or 

Form 1040NR, line 58, 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 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withdrawn by the due date of your return (see page 6 of the instructions) 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 2007, married, and you or your spouse had family

coverage under an HDHP at any time during 2007, enter your additional contribution amount

(see page 4 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 

2007 (see page 4 of the instructions) © Self-only Family

If you were under age 55 at the end of 2007, and on the first day of every month during 2007, you

were, or were considered, an eligible individual with the same coverage, enter $2,850 ($5,650 for

family coverage) (see page 4 of the instructions)

Enter the amount you and your employer contributed to your Archer MSAs for 2007 from Form 

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

2007, 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 2007, see the instructions on page 4 for the 

amount to enter

2

5

4

Employer contributions made to your HSAs for 2007

8

9

12

13

9

Part II

2007

Qualified HSA funding distributions

11 Add lines 9 and 10

10 10

11
Form 8889 (2007)

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

Part-year coverage

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 

44, or Form 1040NR, line 41. Be sure to check box c on Form 1040, line 44, or Form 1040NR,

line 41

19 19

20

22

Part III

Form 8889 (2007) Page 2

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