OMB No. 1545-0074
                                           Health Savings Accounts (HSAs) 
Form  8889
Department of the Treasury                      ▶ Attach to Form 1040, 1040-SR, or 1040-NR.                                  2021
                                                                                                                            Attachment   
Internal Revenue Service         ▶ Go to www.irs.gov/Form8889 for instructions and the latest information.                  Sequence No. 52
Name(s) shown on Form 1040, 1040-SR, or 1040-NR                                         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. 
1     Check the box to indicate your coverage under a high-deductible health plan (HDHP) during 2021. 
      See instructions .    .  . . .     . .    . . . .    . .    . .   . .       . . . .  . .    .  . .   . .       ▶   Self-only       Family 
2     HSA  contributions  you  made  for  2021  (or  those  made  on  your  behalf),  including  those  made  from
      January 1, 2022, through April 15, 2022, that were for 2021.        Do not include employer contributions, 
      contributions through a cafeteria plan, or rollovers. See instructions        . . .  . .    .  . .   . .       .   2 
3     If you were under age 55 at the end of 2021 and, on the first day of          every month during 2021, you
      were,  or  were  considered,  an  eligible  individual  with  the same      coverage,  enter  $3,600  ($7,200  for 
      family coverage). All others, see the instructions for the amount to enter .      .  . .    .  . .   . .       .   3 
4     Enter the amount you and your employer contributed to your Archer MSAs for 2021 from Form 8853, 
      lines 1 and 2. If you or your spouse had family coverage under an HDHP at any time during 2021, also 
      include any amount contributed to your spouse’s Archer MSAs .               . . . .  . .    .  . .   . .       .   4 
5     Subtract line 4 from line 3. If zero or less, enter -0-  .  . .   . .       . . . .  . .    .  . .   . .       .   5 
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 2021, see the instructions for the amount to enter           .       .   6 
7     If you were age 55 or older at the end of 2021, married, and you or your spouse had family coverage 
      under an HDHP at any time during 2021, enter your additional contribution amount. See instructions                 7 
8     Add lines 6 and 7  .     . . .     . .    . . . .    . .    . .   . .       . . . .  . .    .  . .   . .       .   8 
9     Employer contributions made to your HSAs for 2021           . .   . .       . . . .    9 
10    Qualified HSA funding distributions  .      . . .    . .    . .   . .       . . . .    10 
11    Add lines 9 and 10  .    . . .     . .    . . . .    . .    . .   . .       . . . .  . .    .  . .   . .       .   11 
12    Subtract line 11 from line 8. If zero or less, enter -0-  . . .   . .       . . . .  . .    .  . .   . .       .   12 
13    HSA deduction. Enter the smaller of line 2 or line 12 here and on Schedule 1 (Form 1040), Part II, line 13         13 
      Caution: If line 2 is more than line 13, you may have to pay an additional tax. See instructions. 
Part II    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. 
14 a  Total distributions you received in 2021 from all HSAs (see 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 instructions        . .       . . . .  . .    .  . .   . .       .   14b 
c     Subtract line 14b from line 14a .    .    . . . .    . .    . .   . .       . . . .  . .    .  . .   . .       .   14c 
15    Qualified medical expenses paid using HSA distributions (see instructions)  .        . .    .  . .   . .       .   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 Schedule 1 (Form 1040), Part I, line 8e .    .       . . . .  . .    .  . .   . .       .   16 
17 a  If  any  of  the  distributions  included  on  line  16  meet  any  of  the Exceptions  to  the  Additional 
      20% Tax (see instructions), check here .      . .    . .    . .   . .       . . . .  . .    .  . .   ▶
b  Additional 20% tax         (see instructions). Enter 20% (0.20) of the distributions included on line 16 that 
      are  subject  to  the  additional  20%  tax.  Also,  include  this  amount  in  the  total  on Schedule  2  (Form
      1040), Part II, line 17c   . .     . .    . . . .    . .    . .   . .       . . . .  . .    .  . .   . .       .   17b 
Part III   Income and Additional Tax for Failure To Maintain HDHP Coverage. 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 III for each spouse. 
18    Last-month rule .     .  . . .     . .    . . . .    . .    . .   . .       . . . .  . .    .  . .   . .       .   18 
19    Qualified HSA funding distribution .      . . . .    . .    . .   . .       . . . .  . .    .  . .   . .       .   19 
20    Total income.         Add lines 18 and 19. Include this amount on Schedule 1 (Form 1040), Part I, line 8z, 
      and enter “HSA” and the amount on the dotted line  .        . .   . .       . . . .  . .    .  . .   . .       .   20 
21    Additional tax.       Multiply line 20 by 10% (0.10). Include this amount in the total on Schedule 2 (Form
      1040), Part II, line 17d . . .     . .    . . . .    . .    . .   . .       . . . .  . .    .  . .   . .       .   21 
For Paperwork Reduction Act Notice, see your tax return instructions.                      Cat. No. 37621P                   Form 8889 (2021)