8889 Health Savings Accounts (HSAs)

2007 Form 8889
Health Savings Accounts (HSAs)
Purpose:

This is the first circulated draft of the 2007 Form 8889, Health
Savings Accounts (HSAs). The major changes are discussed
below.

TPCC Meeting:

None scheduled, but may be arranged if requested.

Instructions:

The 2007 Instructions for Form 8889 will be circulated later.

Prior Revisions:

The 2006 Form 8889 can be viewed by clicking on the following link:
http://www.irs.gov/pub/irs-pdf/f8889.pdf

Other Products:

Circulations of draft tax forms, instructions, notices, and publications are
posted at http://taxforms.web.irs.gov/draft_products.html.

Comments:

Please call, mail, email, or fax any comments by Friday, September 21, 2007.
Major Changes

1. Year references have been changed.
2. Line 3 - The limit based on a taxpayer's annual deductible has been deleted and the line has
been reworded to take into consideration part-year coverage. (IRC 223(b)(2), IRC 223(b)(8))
3. Line 3 – The dollar amounts of the limit have been adjusted for inflation
(Rev. Proc. 2006-53.24(1))
4. Line 9 – The entry line for line 9 has been indented and new lines 10 and 11 have been added
to add qualified HSA funding distributions to the line 9 amount. (IRC 106(e))
5. Lines 10 and 11 have been renumbered 12 and 13
6. New Part III has been added to account for any additional tax due should a taxpayer fail to
maintain a high deductible health plan. (IRC 106(e)(3), IRC 223(b)(8)(B), IRC 408(d)(9)(D))

FROM:

EMAIL:

PHONE:

FAX:

ROOM:

Paul.W.Miller@irs.gov

202-293-2926

202-283-7008

C7-261

Paul. W. Miller
SE:W:CAR:MP:T:I:F

DATE:

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Form

I.R.S. SPECIFICATIONS
TO BE REMOVED BEFORE PRINTING
INSTRUCTIONS TO PRINTERS
FORM 8889, PAGE 1 of 2
MARGINS: TOP 13mm (1⁄ 2 "), CENTER SIDES. PRINTS: HEAD to HEAD
PAPER: WHITE, WRITING, SUB. 20
INK: BLACK
FLAT SIZE: 216mm (81⁄ 2 ") x 279mm (11")
PERFORATE: (NONE)
DO NOT PRINT — DO NOT PRINT — DO NOT PRINT — DO NOT PRINT

Date

Signature

O.K. to print
Revised proofs
requested

OMB No. 1545-0074

8889

Department of the Treasury
Internal Revenue Service

Action

Health Savings Accounts (HSAs)
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2007

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Attach to Form 1040 or Form 1040NR.

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

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Attachment
Sequence No.

See separate instructions.

Social security number of HSA
beneficiary. If both spouses have
HSAs, see page 2 of the instructions

53

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

HSA Contributions and Deduction. See page 2 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 (see page 2 of the instructions).

1

Check the box to indicate your coverage under a high-deductible health plan (HDHP) during
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2007 (see page 2 of the instructions)

2

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 2 of the
instructions)

3

4

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 3 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

5

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

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 2007, see the instructions on page 3 for the
amount to enter
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)
Add lines 6 and 7
9
Employer contributions made to your HSAs for 2007
10
Qualified HSA funding distributions

7

8
9
10
11
12
13

Add lines 9 and 10
Subtract line 11 from line 8. If zero or less, enter -0HSA deduction. Enter the smaller of line 2 or line 12 here and on Form 1040, line 25, or Form
1040NR, line 25
Caution: If line 2 is more than line 13, you may have to pay an additional tax (see page 4 of the
instructions)

Part II

Self-only

Family

2

3

4
5

6

7
8

11
12
13

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 5 of the 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 page 5 of the instructions)
c Subtract line 14b from line 14a
15 Unreimbursed qualified medical expenses (see page 5 of the instructions)

14b
14c
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
17a If any of the distributions included on line 16 meet any of the Exceptions to the Additional
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10% Tax (see page 5 of the instructions), check here
b Additional 10% tax (see page 5 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
For Paperwork Reduction Act Notice, see page 5 of the instructions.

Cat. No. 37621P

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Form

8889

(2007)

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I.R.S. SPECIFICATIONS
TO BE REMOVED BEFORE PRINTING
INSTRUCTIONS TO PRINTERS
FORM 8889, PAGE 2 of 2
MARGINS: TOP 13mm (1⁄ 2 "), CENTER SIDES. PRINTS: HEAD to HEAD
PAPER: WHITE, WRITING, SUB. 20
INK: BLACK
FLAT SIZE: 216mm (81⁄ 2 ") x 279mm (11")
PERFORATE: (NONE)
DO NOT PRINT — DO NOT PRINT — DO NOT PRINT — DO NOT PRINT

Form 8889 (2007)

Part III

Page

Income and Additional Tax for Failure To Maintain HDHP Coverage. See page XX 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.

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18

18

Qualified HSA distribution

19

Part-year coverage

20

Qualified HSA funding distribution

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

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

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Form

8889

(2007)