Title: 8889 HSA Form - 2024

{ --- Your Identity --- }

YourName:
YourSocSec#:

{ --- Part I --- }

{ Your Coverage }
L1:                 { (answer: Self-Only, Family) }

L2               { HSA contributions you made for 2024 }
                ;

L3		; { If you were under 55 and eligible every month, enter $4,150 ($8,300 for Family Coverage). Or see instructions. (answer: 4150, 8300)}

L4		; { Amount you and your employer contributed to your Archer MSAs for 2024 from Form 8853, lines 1 and 2.}

L6		; { Only enter amount if your spouse has separate HSA and coverage under an HDHP. }

L7		; { Additional contribution amount. }

L9		; { Employer contributions made to your HSAs for 2024. }

L10		; { Qualified HSA funding distributions. }


{ --- Part II --- }

L14a		; { Total distributions you received in 2024 from all HSAs} 

L14b		; { Distributions included in L14a rolled over to another HSA. }

L15		; { Qualified medical expenses paid using HSA distributions }

L17a:	N	 { Do any distributions in L16 meet Exceptions to Addtl 20% tax ? { (answer: Y, N) }


{ --- Part III --- }

L18		; { Last-month rule }

L19		; { Qualified HSA funding distribution }
