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Cat. No. 37621P 14b 14c 17b Form 8889 2017 Page 2 Income and Additional Tax for Failure To Maintain HDHP Coverage. Form Department of the Treasury Internal Revenue Service OMB No* 1545-0074 Health Savings Accounts HSAs Attach to Form 1040 or Form 1040NR* Go to www*irs*gov/Form8889 for instructions and the latest information* Name s shown on Form 1040 or Form 1040NR Attachment Sequence No* 52 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. Check the box to indicate your coverage under a high-deductible health plan HDHP during 2017 see instructions. from January 1 2018 through April 17 2018 that were for 2017. Do not include employer contributions contributions through a cafeteria plan or rollovers see instructions. If you were under age 55 at the end of 2017 and on the first day of every month during 2017 you were or were considered an eligible individual with the same coverage enter 3 400 6 750 for family coverage. All others see the instructions for the amount to enter. Enter the amount you and your employer contributed to your Archer MSAs for 2017 from Form 8853 lines 1 and 2. If you or your spouse had family coverage under an HDHP at any time during 2017 also include any amount contributed to your spouse s Archer MSAs. Subtract line 4 from line 3. If zero or less enter -0-. family coverage under an HDHP at any time during 2017 see the instructions for the amount to enter. If you were age 55 or older at the end of 2017 married and you or your spouse had family coverage under an HDHP at any time during 2017 enter your additional contribution amount see instructions. Add lines 6 and 7. Employer contributions made to your HSAs for 2017. Qualified HSA funding distributions. Add lines 9 and 10. HSA 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 instructions. 14a 17a Family 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. Total distributions you received in 2017 from all HSAs see instructions. b Distributions included on line 14a that you rolled over to another HSA. Also include any excess withdrawn by the due date of your return see instructions. Qualified medical expenses paid using HSA distributions see instructions. Self-only 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. If any of the distributions included on line 16 meet any of the Exceptions to the Additional 20 Tax see instructions check here.

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