Title: 8889 HSA Form - 2025 --- EXAMPLE ---

{ --- Your Identity --- }

YourName:	Raplh Emerson
YourSocSec#:	123-45-6789

{ --- Part I --- }

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

L2     5,400          { HSA contributions you made for 2025 }
       1,200
                ;

L3	4,300	; { If you were under 55 and eligible every month, enter $$4,300 ($8,550 for Family Coverage). Or see instructions. (answer: 4300, 8550)}

L4	45	; { Amount you and your employer contributed to your Archer MSAs for 2025 from Form 8853, lines 1 and 2.}

L6	80	; { Only enter amount if your spouse has separate HSA and coverage under an HDHP. }

L7	100	; { Additional contribution amount. }

L9	95	; { Employer contributions made to your HSAs for 2025. }

L10	500	; { Qualified HSA funding distributions. }


{ --- Part II --- }

L14a	700	; { Total distributions you received in 2025 from all HSAs} 

L14b	200	; { Distributions included in L14a rolled over to another HSA. }

L15	300	; { Qualified medical expenses paid using HSA distributions }

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


{ --- Part III --- }

L18	400	; { Last-month rule }

L19	500	; { Qualified HSA funding distribution }
