Federal Form 8889 (Health Savings Accounts (HSAs)) (2024)

Health Savings Accounts (HSAs)
2023 Form 8889
Form8889Department of the TreasuryInternal Revenue ServiceHealth Savings Accounts (HSAs)OMB No. 1545-00742023Attach to Form 1040, 1040-SR, or 1040-NR.Go to www.irs.gov/Form8889 for instructions and the latest information.Name(s) shown on Form 1040, 1040-SR, or 1040-NRAttachmentSequence No. 52Social 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 IHSA Contributions and Deduction. See the instructions before completing this part. If you are filing jointlyand both you and your spouse each have separate HSAs, complete a separate Part I for each spouse.1Check the box to indicate your coverage under a high-deductible health plan (HDHP) during 2023.See instructions . . . . . . . . . . . . . . . . . . . . . . . . . . . . .HSA contributions you made for 2023 (or those made on your behalf), including those made by theunextended due date of your tax return that were for 2023. Do not include employer contributions,contributions through a cafeteria plan, or rollovers. See instructions . . . . . . . . . . .23If you were under age 55 at the end of 2023 and, on the first day of every month during 2023, youwere, or were considered, an eligible individual with the same coverage, enter $3,850 ($7,750 forfamily coverage). All others, see the instructions for the amount to enter . . . . . . . . . .34Enter the amount you and your employer contributed to your Archer MSAs for 2023 from Form 8853,lines 1 and 2. If you or your spouse had family coverage under an HDHP at any time during 2023, alsoinclude 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 familycoverage under an HDHP at any time during 2023, see the instructions for the amount to enter . .If you were age 55 or older at the end of 2023, married, and you or your spouse had family coverageunder an HDHP at any time during 2023, enter your additional contribution amount. See instructions .Add lines 6 and 7 . . . . . . . . . . . . . . . . . . . . . . . . . . . .Employer contributions made to your HSAs for 2023 . . . . . . . .9Qualified HSA funding distributions . . . . . . . . . . . . . .10Add lines 9 and 10 . . . . . . . . . . . . . . . . . . . . . . . . . . . .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 Schedule 1 (Form 1040), Part II, line 13Caution: If line 2 is more than line 13, you may have to pay an additional tax. See instructions.25678910111213Part IIb Additional 20% tax (see instructions). Enter 20% (0.20) of the distributions included on line 16 thatare subject to the additional 20% tax. Also, include this amount in the total on Schedule 2 (Form1040), Part II, line 17c . . . . . . . . . . . . . . . . . . . . . . . . . . .18192021Family45678111213HSA Distributions. If you are filing jointly and both you and your spouse each have separate HSAs, completea separate Part II for each spouse.14a Total distributions you received in 2023 from all HSAs (see instructions) . . . . . . . . . .b Distributions included on line 14a that you rolled over to another HSA. Also include any excesscontributions (and the earnings on those excess contributions) included on line 14a that werewithdrawn by the due date of your return. See instructions. . . . . . . . . . . . . .c Subtract line 14b from line 14a . . . . . . . . . . . . . . . . . . . . . . . .15Qualified medical expenses paid using HSA distributions (see instructions) . . . . . . . . .16Taxable HSA distributions. Subtract line 15 from line 14c. If zero or less, enter -0-. Also, include thisamount in the total on Schedule 1 (Form 1040), Part I, line 8f . . . . . . . . . . . . . .17a If any of the distributions included on line 16 meet any of the Exceptions to the Additional 20%Tax (see instructions), check here . . . . . . . . . . . . . . . . . . . . . .Part IIISelf-only14a14b14c151617bIncome and Additional Tax for Failure To Maintain HDHP Coverage. See the instructions beforecompleting 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.Last-month rule . . . . . . . . . . . . . . . . . . . . . . . . . . . . .Qualified HSA funding distribution . . . . . . . . . . . . . . . . . . . . . . .Total income. Add lines 18 and 19. Include this amount on Schedule 1 (Form 1040), Part I, line 8f .Additional tax. Multiply line 20 by 10% (0.10). Include this amount in the total on Schedule 2 (Form1040), Part II, line 17d . . . . . . . . . . . . . . . . . . . . . . . . . . .For Paperwork Reduction Act Notice, see your tax return instructions.Cat. No. 37621P18192021Form 8889 (2023)

Extracted from PDF file 2023-federal-form-8889.pdf, last modified October 2023

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