An HSA is a type of savings account that allows you to contribute pre-tax dollars to pay for eligible medical expenses. This form is used to report contributions, distributions, and any earnings from your HSA.
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Part I - HSA Contributions and Deduction: Contributions you've made to your HSA, calculations of your maximum allowable deduction, any employer contributions, and qualified HSA funding distributions are reported here. And calculations to your HSA deduction.
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Part II - HSA Distributions: Distributions, or the money you took out of the HSA during the year, and where we'll specify whether the distribution was used for eligible medical expenses. If they weren't used for such expenses, they might be taxable.
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Part III - Income and Additional Tax for Failure To Maintain HDHP Coverage: This applies if you failed to maintain eligibility (having a high deductible health plan coverage) for the HSA. In this case, you may owe income tax and a 10% additional tax on the amount that was used to determine a Part I deduction.