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Form 8889 — Health Savings Accounts (HSAs)

Reports HSA contributions and distributions and claims the deduction. Required any year you contribute to or spend from an HSA.

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Sample

Illustrative — for learning, not an official copy

IRS Form 8889, Health Savings Accounts, shown as a fillable form: the Department of the Treasury / Internal Revenue Service header, OMB number 1545-0074, attachment sequence number 52, a name and Social Security number block, and line 1 with self-only coverage checked. Part I computes the deduction: line 2 (your own contributions) is $3,200 and highlighted, line 3 (the $4,400 self-only limit), line 9 (employer contributions $750), and line 13 (the HSA deduction $3,200, which flows to Schedule 1 and lowers taxable income) highlighted. Part II, distributions, is blank because the shoebox saver isn't withdrawing yet.

8889
Form
Department of the Treasury
Internal Revenue Service
Health Savings Accounts (HSAs)
▶ Attach to Form 1040. Go to www.irs.gov/Form8889 for instructions.
OMB No. 1545-0074
2026
Attachment
Sequence No. 52
Name(s) shown on Form 1040
Jordan A. Reyes
Social security number
•••-••-7731
Part IHSA Contributions and Deduction
1
Coverage under a high-deductible health plan (HDHP) in 2026:
✕ Self-only Family
2
HSA contributions you made for 2026 (not employer or rollover amounts)what you put in
3,200
3
Limit (self-only $4,400 / family $8,750 for 2026)
4,400
4
Amounts contributed to an Archer MSA
0
5
Subtract line 4 from line 3
4,400
6
Allowable share of line 5 (family/spouse allocation)
4,400
7
Additional contribution if age 55 or older
0
8
Add lines 6 and 7
4,400
9
Employer contributions (excluded from your wages)
750
11
Add lines 9 and 10
750
12
Subtract line 11 from line 8
3,650
13
HSA deduction — smaller of line 2 or line 12. Enter on Schedule 1lowers your taxable income
3,200
Part IIHSA Distributions
Lines 14–16: no distributions this year — blank. (The shoebox saver leaves the money invested and saves receipts to reimburse later.)
For Paperwork Reduction Act Notice, see your tax return instructions.Cat. No. 37621P   Form 8889 (2026)
Fictional specimen for educational use. Name, SSN, and figures are invented and refer to no real person. Form layout is illustrative; always use the current official IRS form.
Sample — for learning. Form 8889 is where the HSA meets your tax return: line 2 ($3,200 you contributed) and line 13 (the $3,200 deduction → Schedule 1) are the figures that lower your taxable income.