1040-ES-E Estimated Tax for Individuals

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FORM 8889, PAGE 1 of 2 (PAGE 2 IS BLANK)
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OMB No. 1545-0074

8889

Department of the Treasury
Internal Revenue Service

Action

Health Savings Accounts (HSAs)
©

2006

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Attach to Form 1040 or Form 1040NR.

Name(s) shown on Form 1040 or Form 1040NR

©

Attachment
Sequence No.

See separate instructions.

Social security number of HSA
beneficiary. If both spouses have
HSAs, see page 2 of the instructions

53

©

Before you begin: Complete Form 8853, Archer MSAs and Long-Term Care Insurance Contracts, if required.
Part I

HSA Contributions and Deduction. See page 2 of 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 (see page 2 of the instructions).

1

Check the box to indicate your coverage under a high-deductible health plan (HDHP) during
©
2006 (see page 2 of the instructions)

2

HSA contributions you made for 2006 (or those made on your behalf), including those made
from January 1, 2007, through April 16, 2007, that were for 2006. Do not include employer
contributions, contributions through a cafeteria plan, or rollovers (see page 2 of the
instructions)

3

4

If you were under age 55 at the end of 2006, and on the first day of every month during 2006, you
were an eligible individual with the same annual deductible and coverage, enter the smaller of:
● Your annual deductible (see page 2 of the instructions), or
● $2,700 ($5,450 for family coverage).
All others, enter the limitation from the worksheet on page 3 of the instructions
Enter the amount you and your employer contributed to your Archer MSAs for 2006 from Form
8853, lines 3 and 4. If you or your spouse had family coverage under an HDHP at any time during
2006, also include any amount contributed to your spouse’s Archer MSAs

5

Subtract line 4 from line 3. If zero or less, enter -0-

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 2006, see the instructions on page 3 for the
amount to enter.
If you were age 55 or older at the end of 2006, married, and you or your spouse had family
coverage under an HDHP at any time during 2006, enter your additional contribution amount
(see page 4 of the instructions)
Add lines 6 and 7
Employer contributions made to your HSAs for 2006
Subtract line 9 from line 8. If zero or less, enter -0HSA deduction. Enter the smaller of line 2 or line 10 here and on Form 1040, line 25, or Form
1040NR, line 25
Caution: If line 2 is more than line 11, you may have to pay an additional tax (see page 4 of the
instructions).

7

8
9
10
11

Part II

Self-only

Family

2

3

4
5

6

7
8
9
10
11

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.

12a Total distributions you received in 2006 from all HSAs (see page 4 of the instructions)

12a

b Distributions included on line 12a that you rolled over to another HSA. Also include any excess
contributions (and the earnings on those excess contributions) included on line 12a that were
withdrawn by the due date of your return (see page 4 of the instructions)
c Subtract line 12b from line 12a
13 Unreimbursed qualified medical expenses (see page 4 of the instructions)

12b
12c
13

14

Taxable HSA distributions. Subtract line 13 from line 12c. 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
15a If any of the distributions included on line 14 meet any of the Exceptions to the Additional
©
10% Tax (see page 5 of the instructions), check here
b Additional 10% tax (see page 5 of the instructions). Enter 10% (.10) of the distributions included
on line 14 that are subject to the additional 10% tax. Also include this amount in the total on
Form 1040, line 63, or Form 1040NR, line 58. On the dotted line next to Form 1040, line 63, or
Form 1040NR, line 58, enter “HSA” and the amount
For Paperwork Reduction Act Notice, see page 5 of the instructions.

Cat. No. 37621P

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15b
Form

8889

(2006)

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Page 1 of 5

Instructions for Form 8889

14:10 - 19-DEC-2005

The type and rule above prints on all proofs including departmental reproduction proofs. MUST be removed before printing.

2005

Department of the Treasury
Internal Revenue Service

Instructions for Form 8889
Health Savings Accounts (HSAs)

General Instructions
Section references are to the Internal
Revenue Code unless otherwise
noted.

the qualified medical expenses of the
account beneficiary or the account
beneficiary’s spouse or dependents.

Distributions From an HSA

Use Form 8889 to:
• Report health savings account
(HSA) contributions (including those
made on your behalf and employer
contributions),
• Figure your HSA deduction, and
• Report distributions from HSAs.
Additional information. See Pub.
969, Health Savings Accounts and
Other Tax-Favored Health Plans, for
more details on HSAs.

Distributions from an HSA used
exclusively to pay qualified medical
expenses of the account beneficiary,
spouse, or dependents are
excludable from gross income. You
can receive distributions from an HSA
even if you are not currently eligible
to have contributions made to the
HSA. However, any part of a
distribution not used to pay qualified
medical expenses is includible in
gross income and is subject to an
additional 10% tax unless an
exception applies.

Who Must File

Qualified Medical Expenses

You must file Form 8889 if any of the
following applies.
• You (or someone on your behalf,
including your employer) made
contributions for 2005 to your HSA.
• You received HSA distributions in
2005.
• You acquired an interest in an HSA
because of the death of the account
beneficiary. See Death of Account
Beneficiary on page 2.

Generally, qualified medical
expenses for HSA purposes are
unreimbursed medical expenses that
could otherwise be deducted on
Schedule A (Form 1040). See the
Instructions for Schedule A and Pub.
502, Medical and Dental Expenses
(Including the Health Coverage Tax
Credit). However, you cannot treat
insurance premiums as qualified
medical expenses unless the
premiums are for:

Purpose of Form

Definitions
Eligible Individual
To be eligible to have contributions
made to your HSA, you must be
covered under a high deductible
health plan (HDHP) and have no
other health coverage except
permitted coverage. If you are an
eligible individual, anyone can
contribute to your HSA. However, you
cannot be enrolled in Medicare or be
claimed as a dependent on another
person’s tax return. You must be an
eligible individual on the first day of a
month to take an HSA deduction for
that month.

• Long-term care (LTC) insurance,
• Health care continuation coverage

(such as coverage under COBRA),
• Health care coverage while
receiving unemployment
compensation under federal or state
law, or
• Medicare and other health care
coverage if you were 65 or older
(other than premiums for a Medicare
supplemental policy, such as
Medigap).

HSA
Generally, an HSA is a health savings
account set up exclusively for paying

An HDHP can provide preventive
care and certain other benefits with
no deductible or a deductible below
the minimum annual deductible. For
more details, see Pub. 969. An HDHP
does not include a plan if
substantially all of the coverage is for
accidents, disability, dental care,
vision care, or long-term care. An
HDHP also cannot be insurance that
you are permitted to have in addition
to an HDHP. See Other Health
Coverage below.

Other Health Coverage
If you have an HSA, you (and your
spouse, if you have family coverage)
generally cannot have any health
coverage other than an HDHP. But
your spouse can have health
coverage other than an HDHP if you
are not covered by that plan. If you
have a health flexible spending
arrangement or health reimbursement
arrangement, see Pub. 969.
Exceptions. You can have additional
insurance that provides benefits only
for:
• Liabilities under workers’
compensation laws, tort liabilities, or
liabilities arising from the ownership
or use of property,
• A specific disease or illness, or
• A fixed amount per day (or other
period) of hospitalization.

High Deductible Health Plan

You can also have coverage
(either through insurance or
otherwise) for accidents, disability,
dental care, vision care, or long-term
care.

An HDHP is a health plan that meets
the following requirements.

For information on prescription
drug plans, see Pub. 969.

Self-only Family
Disabled
coverage coverage An individual generally is considered

Account Beneficiary
The account beneficiary is the
individual on whose behalf the HSA
was established.

* This limit does not apply to deductibles and
expenses for out-of-network services if the plan
uses a network of providers. Instead, only
deductibles and out-of-pocket expenses (such as
copayments and other amounts, but not
premiums) for services within the network should
be used to figure whether the limit is reached.

Minimum annual
deductible

$1,000

Maximum annual
out-of-pocket
expenses*

$5,100 $10,200

Cat. No. 37971Y

$2,000

disabled if he or she is unable to
engage in any substantial gainful
activity due to a physical or mental
impairment which can be expected to
result in death or to continue
indefinitely.

Page 2 of 5

Instructions for Form 8889

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Death of Account Beneficiary

Rollovers

If the account beneficiary’s surviving
spouse is the designated beneficiary,
the HSA is treated as if the surviving
spouse were the account beneficiary.
The surviving spouse completes
Form 8889 as though the HSA
belonged to him or her.
If the designated beneficiary is not
the account beneficiary’s surviving
spouse, or there is no designated
beneficiary, the account ceases to be
an HSA as of the date of death. The
beneficiary completes Form 8889 as
follows.
• Enter “Death of HSA account
beneficiary” across the top of Form
8889.
• Enter the name(s) shown on your
tax return and your SSN in the
spaces provided at the top of the form
and skip Part I.
• On line 12a, enter the fair market
value of the HSA as of the date of
death.
• On line 13, for a beneficiary other
than the estate, enter qualified
medical expenses incurred by the
account beneficiary before the date of
death that you paid within 1 year after
the date of death.
• Complete the rest of Part II.
If the account beneficiary’s estate
is the beneficiary, the value of the
HSA as of the date of death is
included on the account beneficiary’s
final income tax return. Complete
Form 8889 as described above,
except you should complete Part I, if
applicable.
The distribution is not subject to
the additional 10% tax. Report any
earnings on the account after the
date of death as income on your tax
return.

A rollover is a tax-free distribution
(withdrawal) of assets from one HSA
or Archer MSA that is reinvested in
another HSA. Generally, you must
complete the rollover within 60 days
after you received the distribution.
You can make only one rollover
contribution to an HSA during a
1-year period. See Pub. 590,
Individual Retirement Arrangements
(IRAs), for more details and additional
requirements regarding rollovers.
Note. If you instruct the trustee of
your HSA to transfer funds directly to
the trustee of another HSA, the
transfer is not considered a rollover.
There is no limit on the number of
these transfers. Do not include the
amount transferred in income, deduct
it as a contribution, or include it as a
distribution on line 12a.

Specific Instructions
Name and social security number
(SSN). Enter your name(s) as shown
on your tax return and the SSN of the
HSA beneficiary. If married filing
jointly and both you and your spouse
have HSAs, complete a separate
Form 8889 for each of you.

Part I—HSA
Contributions and
Deductions
Use Part I to figure:
• Your HSA deduction,
• Any excess contributions you made
(or those made on your behalf), and
• Any excess contributions made by
an employer (see Excess Employer
Contributions on page 4).

Deemed Distributions From
HSAs

Figuring Your HSA
Deduction

The following situations result in
deemed distributions from your HSA.
• You engaged in any transaction
prohibited by section 4975 with
respect to any of your HSAs, at any
time in 2005. Your account ceases to
be an HSA as of January 1, 2005,
and you must include the fair market
value of all assets in the account as
of January 1, 2005, on line 12a.
• You used any portion of any of
your HSAs as security for a loan at
any time in 2005. You must include
the fair market value of the assets
used as security for the loan as
income on Form 1040, line 21.
Any deemed distribution will not be
treated as used to pay qualified
medical expenses. Generally, these
distributions are subject to the
additional 10% tax.

The amount you can deduct for HSA
contributions is limited by the
applicable portion of the HDHP’s
annual deductible (line 3) reduced by
any contributions to your Archer
MSAs (line 4) and any employer
contributions (line 9). If you were age
55 or older at the end of 2005, you
can increase the contribution limit to
your HSA by up to $600 (line 3 or line
7 depending on your type of coverage
and marital status).
You can make deductible
contributions to your HSA even if your
employer made contributions.
However, if you (or someone on your
behalf) made contributions in addition
to any employer contributions, you
may have to pay an additional tax.
See Excess Contributions You Make
on page 4.
-2-

You cannot deduct any
contributions you made after you
were enrolled in Medicare. Also, you
cannot deduct contributions if you can
be claimed as a dependent on
someone else’s 2005 tax return.

How To Complete Part I
Complete lines 1 through 11 as
instructed on the form. However, if
you, and your spouse if filing jointly,
are both eligible individuals and either
of you have an HDHP with family
coverage, complete a separate Form
8889 for each spouse as follows.
• If either spouse has an HDHP with
family coverage, you both are treated
as having only the family coverage
plan. Disregard any plans with
self-only coverage.
• If both spouses have HDHPs with
family coverage, you both are treated
as having only the family coverage
plan with the lowest annual
deductible.
Combine the amounts on line 11 of
both Forms 8889 and enter this
amount on Form 1040, line 25. Be
sure to attach both Forms 8889 to
your tax return.

Line 1
If you were covered by a self-only
HDHP and a family HDHP at different
times during the year, check the box
for the plan that was in effect for a
longer period. If you were covered by
both a self-only HDHP and a family
HDHP at the same time, you are
treated as having family coverage
during that period.

Line 2
Do not include employer contributions
or amounts rolled over from another
HSA or Archer MSA. See Rollovers
on this page.

Line 3
When figuring the amount to enter on
line 3, apply the following rules.
1. Use the family coverage
amount if you or your spouse had an
HDHP with family coverage.
Disregard any plans with self-only
coverage.
2. If you and your spouse had
more than one HDHP with family
coverage, use the plan with the
lowest annual deductible.
3. If you had family coverage with
both an umbrella deductible and an
embedded deductible for each
individual covered by the plan, your
annual deductible is the smaller of
the:
a. Umbrella deductible, or
b. Embedded individual deductible
multiplied by the number of family
members covered by the plan.

Page 3 of 5

Instructions for Form 8889

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The type and rule above prints on all proofs including departmental reproduction proofs. MUST be removed before printing.

Example. In 2005, you had family
coverage under an HDHP for you and
your spouse. Both of you were under
age 55 at the end of 2005. Your
HDHP will pay benefits for any family
member whose covered expenses
exceed $2,000 (the embedded
individual deductible) and will pay
benefits for all family members after
the covered expenses exceed $5,000
(the umbrella deductible). Your
annual deductible is $4,000 (the
smaller of $5,000 or $4,000 ($2,000 ×
2)). Your maximum HSA deduction is
$4,000 (the smaller of $4,000 or
$5,250).
If you did not have the same
coverage on the first day of every
month during 2005, or you were age
55 or older at the end of 2005, go
through the chart at the top of the
Line 3 Limitation Chart and
Worksheet on this page for each
month of 2005. Enter the result on
the worksheet next to the
corresponding month.
If eligibility and coverage did
TIP not change from one month to
the next, enter the same
number you entered for the previous
month.

Line 6
Spouses that have separate HSAs
and had family coverage under an
HDHP at any time during 2005, use
the following rules to figure the
amount on line 6.
• If you were treated as having family
coverage for each month you were an
eligible individual, divide the amount
on line 5 equally between you and
your spouse, unless you both agree
on a different allocation (such as
allocating nothing to one spouse).
Enter your allocable share on line 6.
• If you were not treated as having
family coverage for each month you
were an eligible individual, use the
following steps to determine the
amount to enter on line 6.
Step 1. Refigure the contribution
limit that would have been entered on
line 5 if you had entered on line 3 the
total of the worksheet amounts only
for the months you were treated as
having family coverage. When
refiguring line 5, use the same
amount you previously entered on
line 4.
Step 2. Divide the refigured
contribution limit from Step 1 equally
between you and your spouse, unless
you both agree on a different
allocation (such as allocating nothing
to one spouse).
Step 3. Subtract the part of the
contribution limit allocated to your
spouse in Step 2 from the amount

Line 3 Limitation Chart and Worksheet
Go through this chart for each month of 2005.
See the instructions for line 3 that begin on page 2.
(Keep for your records)

Start Here
Were you enrolled in Medicare for the
month?

Yes

No
䊲

Were you an eligible individual (see
page 1 of the instructions) on the first
day of the month?

䊲

No

䊳

Enter -0- on the line
below for the month.

Yes
䊲

What type of coverage did your HDHP provide on the first day of the
month (see items (1) through (3) in the instructions for line 3, on page 2)?

Self-only coverage

Family coverage

Enter your annual deductible (must be at
least $1,000 but not more than $2,650)
on the line below for the month. If you
were age 55 or older at the end of 2005,
increase this amount by $600.

Enter your annual deductible (must be at
least $2,000 but not more than $5,250)
on the line below for the month. If, at the
end of 2005, you were unmarried and
age 55 or older, increase this amount by
$600.

Amount from
chart above

Month in 2005
January
February
March
April
May
June
July
August
September
October
November
December
Total for all months
Limit. Divide the total by 12. Enter here and on line 3

-3-

Page 4 of 5

Instructions for Form 8889

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you previously entered on line 5.
Enter the result on line 6.
Example. In 2005, you are an
eligible individual and have self-only
coverage under an HDHP with a
$1,200 deductible. In March, you get
married and as of April 1, you have
family coverage under an HDHP with
a $2,400 deductible. Neither you nor
your spouse were age 55 or older at
the end of 2005 so you do not qualify
for the additional contribution amount.
Your spouse has a separate HSA and
is an eligible individual from April 1
through December 31, 2005. The
contribution limit for the 9 months of
family coverage is $1,800 ($2,400 ×
9/12). You and your spouse can
divide the $1,800 in any allocation
you agree to. Your contribution limit
for the 3 months of self-only coverage
is $300 ($1,200 × 3/12). This amount
is not divided between you and your
spouse. If you and your spouse divide
the contribution limit for the months of
family coverage equally, you will
show $1,200 on line 6 ($2,100 from
your original line 5 minus $900
allocated to your spouse). Your
spouse will show $900 on line 6.

Line 7
Additional Contribution Amount
If, at the end of 2005, you were age
55 or older and married, multiply $50
by the number of months during 2005
that both of the following apply.
1. You or your spouse had family
coverage under an HDHP on the first
day of the month.
2. You were not enrolled in
Medicare for the month.
Enter the result on line 7.
If items (1) and (2) apply to all
TIP months during 2005, enter
$600 on line 7.
Example. At the end of 2005, you
were age 55 and married. You had
family coverage under an HDHP from
July 1 through December 31, 2005 (6
months). You were not enrolled in
Medicare in 2005. You would enter
an additional contribution amount of
$300 on line 7 ($50 × 6 months).

Line 9
Employer Contributions
Employer contributions include any
amount an employer contributes to
any HSA for you for 2005. These
contributions should be shown in box
12 of Form W-2 with code W. If your
employer made excess contributions,
you may have to report the excess as
income. See Excess Employer
Contributions on this page for details.

Line 11
If you or someone on your behalf (or
your employer) contributed more to
your HSA than is allowable, you may
have to pay an additional tax on the
excess contributions. Figure the
excess contributions using the
instructions below. See Form 5329,
Additional Taxes on Qualified Plans
(Including IRAs) and Other
Tax-Favored Accounts, to figure the
additional tax.

Excess Contributions You Make
To figure your excess contributions
(including those made on your
behalf), subtract your deductible
contributions (line 11) from your
actual contributions (line 2). However,
you can withdraw some or all of your
excess contributions for 2005 and
they will be treated as if they had not
been contributed if:
• You make the withdrawal by the
due date, including extensions, of
your 2005 tax return (but see the
Note below),
• You do not claim a deduction for
the amount of the withdrawn
contributions, and
• You also withdraw any income
earned on the withdrawn
contributions and include the
earnings in “Other income” on your
tax return for the year you withdraw
the contributions and earnings.

Excess Employer Contributions
Excess employer contributions are
the excess, if any, of your employer’s
contributions over your limitation on
line 8. If the excess was not included
in income on Form W-2, you must
report it as “Other income” on your
tax return. However, you can
withdraw some or all of the excess
employer contributions for 2005 and
they will be treated as if they had not
been contributed if:
• You make the withdrawal by the
due date, including extensions, of
your 2005 tax return (but see the
Note below),
• You do not claim an exclusion from
income for the amount of the
withdrawn contributions, and
• You also withdraw any income
earned on the withdrawn
contributions and include the
earnings in “Other income” on your
tax return for the year you withdraw
the contributions and earnings.
Note. If you timely filed your return
without withdrawing the excess
contributions, you can still make the
withdrawal no later than 6 months
after the due date of your tax return,
excluding extensions. If you do, file
-4-

an amended return with “Filed
pursuant to section 301.9100-2”
written at the top. Include an
explanation of the withdrawal. Make
all necessary changes on the
amended return (for example, if you
reported the contributions as excess
contributions on your original return,
include an amended Form 5329
reflecting that the withdrawn
contributions are no longer treated as
having been contributed).

Part II—HSA
Distributions
Line 12a
Enter the total distributions you
received in 2005 from all HSAs.
These amounts should be shown in
box 1 of Form 1099-SA.

Line 12b
Include on line 12b any distributions
you received in 2005 that qualified as
a rollover contribution to another
HSA. See Rollovers on page 2. Also
include any excess contributions (and
the earnings on those excess
contributions) included on line 12a
that were withdrawn by the due date,
including extensions, of your return.
See the instructions for line 11 on this
page.

Line 13
Only include on line 13
distributions from your HSA
CAUTION that were used to pay or
reimburse qualified medical expenses
(see page 1) you incurred on or after
the first day of the first month you
became an eligible individual (see
page 1).

!

In general, include on line 13
distributions from all HSAs in 2005
that were used for the qualified
medical expenses (see page 1) of:
• Yourself and your spouse.
• All dependents you claim on your
tax return.
• Any person you could have
claimed as a dependent on your
return except that person received
$3,200 or more of gross income or
filed a joint return.
• Any person you could have
claimed as a dependent except that
you, or your spouse if filing jointly,
were claimed as a dependent on
someone else’s 2005 return.

!

CAUTION

line 13.

You cannot take a deduction
on Schedule A (Form 1040)
for any amount you include on

Page 5 of 5

Instructions for Form 8889

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Lines 15a and 15b
Additional 10% Tax
HSA distributions included in income
(line 14) are subject to an additional
10% tax unless one of the following
exceptions apply.

Exceptions to the Additional
10% Tax
The additional 10% tax does not
apply to distributions made after the
account beneficiary —
• Dies,
• Becomes disabled (see page 1), or
• Turns age 65.
If any of the exceptions apply to
any of the distributions included on
line 14, check the box on line 15a.
Enter on line 15b only 10% (.10) of
any amount included on line 14 that
does not meet any of the exceptions.
Example 1. You turned age 63 in
2005 and received a distribution from
an HSA that is included in income. Do
not check the box on line 15a
because you (the account
beneficiary) did not meet the age

exception for the distribution. Enter
10% of the amount from line 14 on
line 15b.
Example 2. You turned age 65 in
2005. You received distributions that
are included in income both before
and after you turned age 65. Check
the box on line 15a because the
additional 10% tax does not apply to
the distributions made after the date
you turned age 65. However, the
additional 10% tax does apply to the
distributions made on or before the
date you turned age 65. Enter on line
15b, 10% of the amount of these
distributions included in line 14.
Paperwork Reduction Act Notice.
We ask for the information on this
form to carry out the Internal
Revenue laws of the United States.
You are required to give us the
information. We need it to ensure that
you are complying with these laws
and to allow us to figure and collect
the right amount of tax.

-5-

You are not required to provide the
information requested on a form that
is subject to the Paperwork Reduction
Act unless the form displays a valid
OMB control number. Books or
records relating to a form or its
instructions must be retained as long
as their contents may become
material in the administration of any
Internal Revenue law. Generally, tax
returns and return information are
confidential, as required by section
6103.
The average time and expenses
required to complete and file this form
will vary depending on individual
circumstances. For the estimated
averages, see the instructions for
your income tax return.
If you have suggestions for making
this form simpler, we would be happy
to hear from you. See the instructions
for your income tax return.

4
TLS, have you
transmitted all R
text files for this
cycle update?

Date

Form

I.R.S. SPECIFICATIONS
TO BE REMOVED BEFORE PRINTING
INSTRUCTIONS TO PRINTERS
FORM 8891, PAGE 1 OF 2
MARGINS; TOP 13mm (1/2"), CENTER SIDES. PRINTS: HEAD TO HEAD
PAPER: WHITE WRITING, SUB. 20.
INK: BLACK
FLAT SIZE: 216mm (8-1/2") x 279mm (11")
PERFORATE: None
DO NOT PRINT — DO NOT PRINT — DO NOT PRINT — DO NOT PRINT

8891

Action

Date

O.K. to print
Revised proofs
requested

U.S. Information Return for Beneficiaries of
Certain Canadian Registered Retirement Plans

Department of the Treasury
Internal Revenue Service

䊳

Attach to Form 1040.

䊳

Signature

OMB No. 1545-0074

2005

See instructions on back of form.

Name shown on Form 1040

Attachment
Sequence No.

139

Identifying number (see instructions)

1

Name of plan custodian

2

Account number of plan

3

Address of plan custodian

4

Type of plan (check one box):
Registered Retirement Savings Plan (RRSP)
Registered Retirement Income Fund (RRIF)

5

Check the applicable box for your status in the plan (see Definitions in the instructions):
Beneficiary
Annuitant (Complete only lines 7a, 7b, and 8.)

6a Have you previously made an election under Article XVIII(7) of the U.S.–Canada income tax treaty to
䊳
defer U.S. income tax on the undistributed earnings of the plan?
b If “Yes,” enter the first year the election came into effect

Yes

No

and go to line 7a. If “No,” go to line 6c.

c If you have not previously made the election described on line 6a above, you can make an irrevocable
䊳
election for this year and subsequent years by checking this box

7a Distributions received from the plan during the year. Enter here and include on Form 1040,
line 16a

7a

b Taxable distributions received from the plan during the year. Enter here and include on
Form 1040, line 16b

7b

8

9
10

Plan balance at the end of the year. If you checked the “Annuitant” box on line 5, the “Yes” box
on line 6a, or the box on line 6c, stop here. Do not complete the rest of the form

8

Contributions to the plan during the year

9

Undistributed earnings of the plan during the year:

a Interest income. Enter here and include on Form 1040, line 8a

10a

b Total ordinary dividends. Enter here and include on Form 1040, line 9a

10b

c Qualified dividends. Enter here and include on Form 1040, line 9b

10c

d Capital gains. See the instructions for Form 1040, line 13, for how to report

10d

e Other income. Enter here and include on Form 1040, line 21. List type and amount

䊳

10e
For Paperwork Reduction Act Notice, see page 2.

Cat. No. 37699X

Form

8891

(2005)

4
I.R.S. SPECIFICATIONS
TO BE REMOVED BEFORE PRINTING
INSTRUCTIONS TO PRINTERS
FORM 8891, PAGE 2 OF 2
MARGINS; TOP 13mm (1/2"), CENTER SIDES. PRINTS: HEAD TO HEAD
PAPER: WHITE WRITING, SUB. 20.
INK: BLACK
FLAT SIZE: 216mm (8-1/2") x 279mm (11")
PERFORATE: None
DO NOT PRINT — DO NOT PRINT — DO NOT PRINT — DO NOT PRINT

Form 8891 (2005)

Page

General Instructions

Specific Instructions

Section references are to the Internal Revenue Code.

All amounts listed must be in U.S. dollars.

Purpose of Form

Name

Form 8891 is used by U.S. citizens or residents (a) to report
contributions to Canadian registered retirement savings plans
(RRSPs) and registered retirement income funds (RRIFs), (b)
to report undistributed earnings in RRSPs and RRIFs, and (c)
to report distributions received from RRSPs and RRIFs. See
Notice 2003-75, which is available at www.irs.gov.
Form 8891 also may be used to make an election pursuant
to Article XVIII(7) of the U.S.-Canada income tax treaty to
defer U.S. income tax on income earned by an RRSP or an
RRIF that has been accrued, but not distributed. The
procedures for making the election are described in Revenue
Procedure 2002-23, which is available at www.irs.gov.
Taxpayers who have not previously made the election under
Revenue Procedure 2002-23 may make it on this form.

2

Even if you are filing a joint Form 1040 with your spouse,
enter only your name.

Identifying number
Enter your U.S. social security number (SSN) or individual
taxpayer identification number (ITIN). Do not enter a
Canadian identifying number.

Beneficiaries
A beneficiary who has previously made the election to defer
income on the plan or is making it initially by checking the
box on line 6c, must only complete lines 1 through 8 of the
form.

Who Must File

Annuitants

Form 8891 must be completed and attached to Form 1040
by any U.S. citizen or resident who is a beneficiary of an
RRSP or RRIF. A U.S. citizen or resident who is an annuitant
of an RRSP or RRIF must file the form for any year in which
he or she receives a distribution from the RRSP or RRIF.

If you are treated as an annuitant for purposes of this form
(see Definitions), you should complete only lines 1 through 5,
7a, 7b, and 8.

A separate Form 8891 must be filed for each RRSP or
RRIF for which there is a filing requirement. If you and your
spouse both must file Form 8891, you each must file a
separate Form 8891.

If the election you made previously was made under Rev.
Proc. 89-45, check the “No” box. If an election (other than an
election under Rev. Proc. 89-45) was made for an RRSP, and
amounts from the RRSP were rolled over tax-free to an RRIF
or another RRSP, the election is considered to have been
made for the plan which received the tax-free rollover.

Definitions
Beneficiary. A beneficiary of an RRSP or RRIF is an
individual who is subject to current U.S. income taxation on
income accrued in the RRSP or RRIF or would be subject to
current income taxation had the individual not made the
election under Article XVIII(7) of the U.S.–Canada income tax
treaty to defer U.S. income taxation of income accrued in the
RRSP or RRIF.
Annuitant. For purposes of this form, an annuitant of an
RRSP or RRIF is an individual who is designated pursuant to
the RRSP or RRIF as an annuitant and is not also a
beneficiary as defined above.

Record Retention
Taxpayers must retain supporting documentation relating to
the information reported on Form 8891, including Canadian
forms T4RSP, T4RIF, or NR4, and periodic or annual
statements issued by the custodian of the RRSP or RRIF.

Other Reporting Requirements
Pursuant to section 6048(d)(4), annuitants and beneficiaries
who are required to file Form 8891 will not be required to file
Form 3520, and will not be subject to the associated
penalties described in section 6677 on such RRSPs or
RRIFs.
You may be required to file Form TD F 90-22.1. See the
instructions for Form 1040.

Line 6

Line 7(b)
For information on figuring taxable distributions, see section
72 and Pub. 939, General Rule for Pensions and Annuities.

Paperwork Reduction Act Notice
We ask for the information on this form to carry out the
Internal Revenue laws of the United States. You are required
to give us the information. We need it to ensure that you are
complying with these laws and to allow us to figure and
collect the right amount of tax.
You are not required to provide the information requested
on a form that is subject to the Paperwork Reduction Act
unless the form displays a valid OMB control number. Books
or records relating to a form or its instructions must be
retained as long as their contents may become material in
the administration of any Internal Revenue law. Generally, tax
returns and return information are confidential, as required by
Internal Revenue Code section 6103.
The average time and expenses required to complete and
file this form will vary depending on individual circumstances.
For the estimated averages, see the instructions for your
income tax return.
If you have suggestions for making this form simpler, we
would be happy to hear from you. See the Instructions for
your income tax return.