Form 8959

Department of the Treasury 

Internal Revenue Service 

Additional Medicare Tax

▶ If any line does not apply to you, leave it blank. See separate instructions. 

▶ Attach to Form 1040, 1040NR, 1040-PR, or 1040-SS.

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

OMB No. 1545-0074

2016

Attachment 

Sequence No. 71

Name(s) shown on return Your 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) $200,000 5 

6 Subtract line 5 from line 4. If zero or less, enter -0- . . . . . . . . . . . . . . 6 

7 Additional Medicare Tax on Medicare wages. Multiply line 6 by 0.9% (0.009). 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 

9 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) $200,000 9

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 zero or less, enter -0- . . . . . . . . . . . . . . 12 

13 Additional Medicare Tax on self-employment income. Multiply line 12 by 0.9% (0.009). Enter 

here and go to Part III . . . . . . . . . . . . . . . . . . . . . . . . 13 

Part III Additional Medicare Tax on Railroad Retirement Tax Act (RRTA) Compensation

14 Railroad retirement (RRTA) compensation and tips from 

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

15 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) $200,000 15

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% (0.009). 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 62, (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

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

21 Multiply line 20 by 1.45% (0.0145). This is your regular 

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

22 Subtract line 21 from line 19. If zero or less, enter -0-. This is your Additional Medicare Tax 

withholding on Medicare wages . . . . . . . . . . . . . . . . . . . . 22

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

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

24 Total Additional Medicare Tax withholding. Add lines 22 and 23. Also include this 

amount with federal income tax withholding on Form 1040, line 64 (Form 1040NR, 1040-PR, 

and 1040-SS filers, see instructions) . . . . . . . . . . . . . . . . . . . 24

For Paperwork Reduction Act Notice, see your tax return instructions. Cat. No. 59475X Form 8959 (2016)