Form 8889

Department of the Treasury 

Internal Revenue Service 

Health Savings Accounts (HSAs) 

▶ Attach to Form 1040 or Form 1040NR. ▶ See separate instructions. 

OMB No. 1545-0074

2011

Attachment 

Sequence No. 53

Name(s) shown on Form 1040 or Form 1040NR Social security number of HSA 

beneficiary. If both spouses have 

HSAs, see instructions ▶

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

Part I HSA Contributions and Deduction. See 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. 

1 Check the box to indicate your coverage under a high-deductible health plan (HDHP) during 

2011 (see instructions). . . . . . . . . . . . . . . . . . . . . . . . ▶ Self-only Family 

2 HSA contributions you made for 2011 (or those made on your behalf), including those made 

from January 1, 2012, through April 17, 2012, that were for 2011. Do not include employer 

contributions, contributions through a cafeteria plan, or rollovers (see instructions) . . . . . 2 

3 If you were under age 55 at the end of 2011, and on the first day of every month during 2011, 

you were, or were considered, an eligible individual with the same coverage, enter $3,050

($6,150 for family coverage). All others, see the instructions for the amount to enter . . . . 3 

4 Enter the amount you and your employer contributed to your Archer MSAs for 2011 from Form 

8853, lines 1 and 2. If you or your spouse had family coverage under an HDHP at any time

during 2011, also include any amount contributed to your spouse’s Archer MSAs . . . . . 4 

5 Subtract line 4 from line 3. If zero or less, enter -0- . . . . . . . . . . . . . . . 5 

6 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 2011, see the instructions for the amount to 

enter . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6 

7 If you were age 55 or older at the end of 2011, married, and you or your spouse had family 

coverage under an HDHP at any time during 2011, enter your additional contribution amount 

(see instructions) . . . . . . . . . . . . . . . . . . . . . . . . . . 7 

8 Add lines 6 and 7 . . . . . . . . . . . . . . . . . . . . . . . . . . 8 

9 Employer contributions made to your HSAs for 2011 . . . . 9 

10 Qualified HSA funding distributions . . . . . . . . . . 10 

11 Add lines 9 and 10 . . . . . . . . . . . . . . . . . . . . . . . . . . 11 

12 Subtract line 11 from line 8. If zero or less, enter -0- . . . . . . . . . . . . . . . 12 

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

1040NR, line 25 . . . . . . . . . . . . . . . . . . . . . . . . . . . 13 

Caution: If line 2 is more than line 13, you may have to pay an additional tax (see instructions). 

Part II 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. 

14 a Total distributions you received in 2011 from all HSAs (see instructions) . . . . . . . . 14a 

b 

 

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 instructions) . . . . . . . . . . . . 14b 

c Subtract line 14b from line 14a . . . . . . . . . . . . . . . . . . . . . . 14c 

15 Unreimbursed qualified medical expenses (see instructions) . . . . . . . . . . . . 15 

16 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 

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

20% Tax (see instructions), check here . . . . . . . . . . . . . . . . . ▶

b 

 

 

Additional 20% tax (see instructions). Enter 20% (.20) of the distributions included on line 16 

that are subject to the additional 20% tax. Also include this amount in the total on Form 1040, 

line 60, or Form 1040NR, line 59. On the dotted line next to Form 1040, line 60, or Form

1040NR, line 59, enter “HSA” and the amount . . . . . . . . . . . . . . . . . 17b 

For Paperwork Reduction Act Notice, see your tax return instructions. Cat. No. 37621P Form 8889 (2011) 
Form 8889 (2011) Page 2 

Part III Income and Additional Tax for Failure To Maintain HDHP Coverage. See 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 . . . . . . . . . . . . . . . . . . . . . . . 18 

19 Last-month rule . . . . . . . . . . . . . . . . . . . . . . . . . . . 19 

20 Qualified HSA funding distribution . . . . . . . . . . . . . . . . . . . . . 20 

21 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 . . . . . . . . . . . . . . . . . . . . . . . . 21 

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

60, or Form 1040NR, line 59. On the dotted line next to Form 1040, line 60, or Form 1040NR, 

line 59, enter “HDHP” and the amount . . . . . . . . . . . . . . . . . . . 22 

Form 8889 (2011)