2023 Income Tax Return

Federal Return

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 Instructions to Mail Federal Tax Return for:
MARY ELLEN OSWALD
23 SCUPPO RD, APT 3-11
DANBURY, CT 06811

Your federal tax return shows a refund of $297. Please be sure to complete the following checklist to finish filing your
taxes. Your federal tax return is due April 15, 2024.

_________________________________________________________________________________________________

Print and Sign Your Return

_________________________________________________________________________________________________

Print a copy of your tax return.

Sign and date the Form 1040 in the Sign Here section.

_________________________________________________________________________________________________

Attach Documents
_________________________________________________________________________________________________

Attach the federal copy of your W-2s.

_________________________________________________________________________________________________

Mail Your Return

_________________________________________________________________________________________________

Keep these instructions along with a copy of your tax return for your records.
Mail your federal tax return to the IRS address listed below.

Department of the Treasury

Internal Revenue Service
Kansas City, MO 64999-0002
 DO NOT MAIL - For your records only

Audit Protection
Your 2023 tax return defense code

TH23-Z3ZG-YWZX-KY6P

Contact Protection Plus if you are audited

866-942-8348

S [email protected]

<f) taxprotectionplus.com/contact-us

CDA
 1040 U.S. Individual Income Tax Return 2023
Form Department of the Treasury—Internal Revenue Service

OMB No. 1545-0074 IRS Use Only—Do not write or staple in this space.

For the year Jan. 1–Dec. 31, 2023, or other tax year beginning , 2023, ending , 20 See separate instructions.
Your first name and middle initial Last name Your social security number
MARY ELLEN OSWALD 047 56 3507
If joint return, spouse’s first name and middle initial Last name Spouse’s social security number

Home address (number and street). If you have a P.O. box, see instructions. Apt. no. Presidential Election Campaign
23 SCUPPO RD, 3-11 Check here if you, or your
City, town, or post office. If you have a foreign address, also complete spaces below. State ZIP code spouse if filing jointly, want $3
to go to this fund. Checking a
DANBURY CT 06811 box below will not change
Foreign country name Foreign province/state/county Foreign postal code your tax or refund.
You Spouse

Filing Status X Single Head of household (HOH)

Married filing jointly (even if only one had income)
Check only
one box. Married filing separately (MFS) Qualifying surviving spouse (QSS)
If you checked the MFS box, enter the name of your spouse. If you checked the HOH or QSS box, enter the child’s name if the
qualifying person is a child but not your dependent:

Digital At any time during 2023, did you: (a) receive (as a reward, award, or payment for property or services); or (b) sell,
Assets exchange, or otherwise dispose of a digital asset (or a financial interest in a digital asset)? (See instructions.) Yes X No
Standard Someone can claim: You as a dependent Your spouse as a dependent
Deduction Spouse itemizes on a separate return or you were a dual-status alien

Age/Blindness You: Were born before January 2, 1959 Are blind Spouse: Was born before January 2, 1959 Is blind
Dependents (see instructions): (2) Social security (3) Relationship (4) Check the box if qualifies for (see instructions):
(1) First name Last name number to you Child tax credit Credit for other dependents
If more
than four
dependents,
see instructions
and check
here . .

Income 1a Total amount from Form(s) W-2, box 1 (see instructions) . . . . . . . . . . . . . 1a 63,032.
b Household employee wages not reported on Form(s) W-2 . . . . . . . . . . . . . 1b
Attach Form(s)
W-2 here. Also c Tip income not reported on line 1a (see instructions) . . . . . . . . . . . . . . 1c
attach Forms d Medicaid waiver payments not reported on Form(s) W-2 (see instructions) . . . . . . . . 1d
W-2G and
1099-R if tax e Taxable dependent care benefits from Form 2441, line 26 . . . . . . . . . . . . 1e
was withheld. f Employer-provided adoption benefits from Form 8839, line 29 . . . . . . . . . . . 1f
If you did not g Wages from Form 8919, line 6 . . . . . . . . . . . . . . . . . . . . . 1g
get a Form
W-2, see
h Other earned income (see instructions) . . . . . . . . . . . . . . . . . . 1h
instructions. i Nontaxable combat pay election (see instructions) . . . . . . . 1i
z Add lines 1a through 1h . . . . . . . . . . . . . . . . . . . . . . 1z 63,032.
Attach Sch. B 2a Tax-exempt interest . . . 2a b Taxable interest . . . . . 2b
if required. 3a Qualified dividends . . . 3a b Ordinary dividends . . . . . 3b
4a IRA distributions . . . . 4a b Taxable amount . . . . . . 4b
Standard
Deduction for— 5a Pensions and annuities . . 5a b Taxable amount . . . . . . 5b
• Single or 6a Social security benefits . . 6a b Taxable amount . . . . . . 6b
Married filing
separately, c If you elect to use the lump-sum election method, check here (see instructions) . . . . .
$13,850 7 Capital gain or (loss). Attach Schedule D if required. If not required, check here . . . . . 7 0.
• Married filing
jointly or 8 Additional income from Schedule 1, line 10 . . . . . . . . . . . . . . . . . 8 2,700.
Qualifying
surviving spouse, 9 Add lines 1z, 2b, 3b, 4b, 5b, 6b, 7, and 8. This is your total income . . . . . . . . . . 9 65,732.
$27,700
• Head of
10 Adjustments to income from Schedule 1, line 26 . . . . . . . . . . . . . . . 10 0.
household, 11 Subtract line 10 from line 9. This is your adjusted gross income . . . . . . . . . . 11 65,732.
$20,800
• If you checked
12 Standard deduction or itemized deductions (from Schedule A) . . . . . . . . . . 12 15,393.
any box under 13 Qualified business income deduction from Form 8995 or Form 8995-A . . . . . . . . . 13
Standard
Deduction, 14 Add lines 12 and 13 . . . . . . . . . . . . . . . . . . . . . . . . 14 15,393.
see instructions.
15 Subtract line 14 from line 11. If zero or less, enter -0-. This is your taxable income . . . . . 15 50,339.
For Disclosure, Privacy Act, and Paperwork Reduction Act Notice, see separate instructions. Cat. No. 11320B Form 1040 (2023)

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Form 1040 (2023) MARY ELLEN OSWALD 047-56-3507 Page 2
Tax and 16 Tax (see instructions). Check if any from Form(s): 1 8814 2 4972 3 . . 16 6,379.
Credits 17 Amount from Schedule 2, line 3 . . . . . . . . . . . . . . . . . . . . 17 0.
18 Add lines 16 and 17 . . . . . . . . . . . . . . . . . . . . . . . . 18 6,379.
19 Child tax credit or credit for other dependents from Schedule 8812 . . . . . . . . . . 19
20 Amount from Schedule 3, line 8 . . . . . . . . . . . . . . . . . . . . 20 0.
21 Add lines 19 and 20 . . . . . . . . . . . . . . . . . . . . . . . . 21 0.
22 Subtract line 21 from line 18. If zero or less, enter -0- . . . . . . . . . . . . . . 22 6,379.
23 Other taxes, including self-employment tax, from Schedule 2, line 21 . . . . . . . . . 23
24 Add lines 22 and 23. This is your total tax . . . . . . . . . . . . . . . . . 24 6,379.
Payments 25 Federal income tax withheld from:
a Form(s) W-2 . . . . . . . . . . . . . . . . . . 25a 6,676.
b Form(s) 1099 . . . . . . . . . . . . . . . . . . 25b
c Other forms (see instructions) . . . . . . . . . . . . . 25c
d Add lines 25a through 25c . . . . . . . . . . . . . . . . . . . . . . 25d 6,676.
If you have a 26 2023 estimated tax payments and amount applied from 2022 return . . . . . . . . . . 26
qualifying child, 27 Earned income credit (EIC) . . . . . . . . . . . . . . 27
attach Sch. EIC.
28 Additional child tax credit from Schedule 8812 . . . . . . . . 28
29 American opportunity credit from Form 8863, line 8 . . . . . . . 29
30 Reserved for future use . . . . . . . . . . . . . . . 30
31 Amount from Schedule 3, line 15 . . . . . . . . . . . . 31
32 Add lines 27, 28, 29, and 31. These are your total other payments and refundable credits . . 32
33 Add lines 25d, 26, and 32. These are your total payments . . . . . . . . . . . . 33 6,676.
Refund 34 If line 33 is more than line 24, subtract line 24 from line 33. This is the amount you overpaid . . 34 297.
35a Amount of line 34 you want refunded to you. If Form 8888 is attached, check here . . . . 35a 297.
Direct deposit? b Routing number 2 2 1 1 7 4 5 0 8 c Type: X Checking Savings
See instructions.
d Account number 1 4 0 0 0 1 2 5 8 3 5 8 4
36 Amount of line 34 you want applied to your 2024 estimated tax . . . 36
Amount 37 Subtract line 33 from line 24. This is the amount you owe.
You Owe For details on how to pay, go to www.irs.gov/Payments or see instructions . . . . . . . . 37 0.
38 Estimated tax penalty (see instructions) . . . . . . . . . . 38
Third Party Do you want to allow another person to discuss this return with the IRS? See
Designee instructions . . . . . . . . . . . . . . . . . . . . . Yes. Complete below. X No
Designee’s Phone Personal identification
name no. number (PIN)

Sign Under penalties of perjury, I declare that I have examined this return and accompanying schedules and statements, and to the best of my knowledge and
belief, they are true, correct, and complete. Declaration of preparer (other than taxpayer) is based on all information of which preparer has any knowledge.
Here Your signature Date Your occupation If the IRS sent you an Identity
Protection PIN, enter it here
(see inst.)
Joint return? CUSTOMER SERVICE
See instructions. Spouse’s signature. If a joint return, both must sign. Date Spouse’s occupation If the IRS sent your spouse an
Keep a copy for Identity Protection PIN, enter it here
your records. (see inst.)

Phone no. Email address

Preparer’s name Preparer’s signature Date PTIN Check if:
Paid Self-employed
SELF-PREPARED
Preparer
Firm’s name Phone no.
Use Only
Firm’s address Firm’s EIN
Go to www.irs.gov/Form1040 for instructions and the latest information. Form 1040 (2023)

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SCHEDULE 1 OMB No. 1545-0074
Additional Income and Adjustments to Income
(Form 1040)
Department of the Treasury
Attach to Form 1040, 1040-SR, or 1040-NR. 2023
Attachment
Go to www.irs.gov/Form1040 for instructions and the latest information.
Internal Revenue Service Sequence No. 01
Name(s) shown on Form 1040, 1040-SR, or 1040-NR Your social security number
MARY ELLEN OSWALD 047-56-3507
Part I Additional Income
1 Taxable refunds, credits, or offsets of state and local income taxes . . . . . . . . . 1
2a Alimony received . . . . . . . . . . . . . . . . . . . . . . . . . . . 2a
b Date of original divorce or separation agreement (see instructions):
3 Business income or (loss). Attach Schedule C . . . . . . . . . . . . . . . . . 3
4 Other gains or (losses). Attach Form 4797 . . . . . . . . . . . . . . . . . . 4
5 Rental real estate, royalties, partnerships, S corporations, trusts, etc. Attach Schedule E . 5
6 Farm income or (loss). Attach Schedule F . . . . . . . . . . . . . . . . . . . 6
7 Unemployment compensation . . . . . . . . . . . . . . . . . . . . . . . 7 2,700.
8 Other income:
a Net operating loss . . . . . . . . . . . . . . . . . . . 8a ( )
b Gambling . . . . . . . . . . . . . . . . . . . . . . 8b
c Cancellation of debt . . . . . . . . . . . . . . . . . . 8c
d Foreign earned income exclusion from Form 2555 . . . . . . . 8d ( )
e Income from Form 8853 . . . . . . . . . . . . . . . . . 8e
f Income from Form 8889 . . . . . . . . . . . . . . . . . 8f
g Alaska Permanent Fund dividends . . . . . . . . . . . . . 8g
h Jury duty pay . . . . . . . . . . . . . . . . . . . . . 8h
i Prizes and awards . . . . . . . . . . . . . . . . . . . 8i
j Activity not engaged in for profit income . . . . . . . . . . . 8j
k Stock options . . . . . . . . . . . . . . . . . . . . . 8k
l Income from the rental of personal property if you engaged in the rental
for profit but were not in the business of renting such property . . . 8l
m Olympic and Paralympic medals and USOC prize money (see
instructions) . . . . . . . . . . . . . . . . . . . . . 8m
n Section 951(a) inclusion (see instructions) . . . . . . . . . . 8n
o Section 951A(a) inclusion (see instructions) . . . . . . . . . . 8o
p Section 461(l) excess business loss adjustment . . . . . . . . 8p
q Taxable distributions from an ABLE account (see instructions) . . . 8q
r Scholarship and fellowship grants not reported on Form W-2 . . . 8r
s Nontaxable amount of Medicaid waiver payments included on Form
1040, line 1a or 1d . . . . . . . . . . . . . . . . . . . 8s ( )
t Pension or annuity from a nonqualifed deferred compensation plan or
a nongovernmental section 457 plan . . . . . . . . . . . . 8t
u Wages earned while incarcerated . . . . . . . . . . . . . 8u
z Other income. List type and amount:
8z
9 Total other income. Add lines 8a through 8z . . . . . . . . . . . . . . . . . . 9
10 Combine lines 1 through 7 and 9. This is your additional income. Enter here and on Form
1040, 1040-SR, or 1040-NR, line 8 . . . . . . . . . . . . . . . . . . . . . 10 2,700.
For Paperwork Reduction Act Notice, see your tax return instructions. Cat. No. 71479F Schedule 1 (Form 1040) 2023

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Schedule 1 (Form 1040) 2023 Page 2

Part II Adjustments to Income

11 Educator expenses . . . . . . . . . . . . . . . . . . . . . . . . . . . 11
12 Certain business expenses of reservists, performing artists, and fee-basis government
officials. Attach Form 2106 . . . . . . . . . . . . . . . . . . . . . . . . 12
13 Health savings account deduction. Attach Form 8889 . . . . . . . . . . . . . . 13
14 Moving expenses for members of the Armed Forces. Attach Form 3903 . . . . . . . 14
15 Deductible part of self-employment tax. Attach Schedule SE . . . . . . . . . . . 15
16 Self-employed SEP, SIMPLE, and qualified plans . . . . . . . . . . . . . . . . 16
17 Self-employed health insurance deduction . . . . . . . . . . . . . . . . . . 17
18 Penalty on early withdrawal of savings . . . . . . . . . . . . . . . . . . . . 18
19a Alimony paid . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19a
b Recipient’s SSN . . . . . . . . . . . . . . . . . . . . . .
c Date of original divorce or separation agreement (see instructions):
20 IRA deduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20
21 Student loan interest deduction . . . . . . . . . . . . . . . . . . . . . . 21
22 Reserved for future use . . . . . . . . . . . . . . . . . . . . . . . . . 22
23 Archer MSA deduction . . . . . . . . . . . . . . . . . . . . . . . . . 23
24 Other adjustments:
a Jury duty pay (see instructions) . . . . . . . . . . . . . . 24a
b Deductible expenses related to income reported on line 8l from the
rental of personal property engaged in for profit . . . . . . . . 24b
c Nontaxable amount of the value of Olympic and Paralympic medals
and USOC prize money reported on line 8m . . . . . . . . . . 24c
d Reforestation amortization and expenses . . . . . . . . . . . 24d
e Repayment of supplemental unemployment benefits under the Trade
Act of 1974 . . . . . . . . . . . . . . . . . . . . . . 24e
f Contributions to section 501(c)(18)(D) pension plans . . . . . . . 24f
g Contributions by certain chaplains to section 403(b) plans . . . . 24g
h Attorney fees and court costs for actions involving certain unlawful
discrimination claims (see instructions) . . . . . . . . . . . . 24h
i Attorney fees and court costs you paid in connection with an award
from the IRS for information you provided that helped the IRS detect
tax law violations . . . . . . . . . . . . . . . . . . . 24i
j Housing deduction from Form 2555 . . . . . . . . . . . . . 24j
k Excess deductions of section 67(e) expenses from Schedule K-1 (Form
1041) . . . . . . . . . . . . . . . . . . . . . . . . 24k
z Other adjustments. List type and amount:
24z
25 Total other adjustments. Add lines 24a through 24z . . . . . . . . . . . . . . . 25
26 Add lines 11 through 23 and 25. These are your adjustments to income. Enter here and on
Form 1040, 1040-SR, or 1040-NR, line 10 . . . . . . . . . . . . . . . . . . 26
Schedule 1 (Form 1040) 2023

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SCHEDULE A Itemized Deductions OMB No. 1545-0074
(Form 1040)
Department of the Treasury
Attach to Form 1040 or 1040-SR.
Go to www.irs.gov/ScheduleA for instructions and the latest information. 2023
Attachment
Internal Revenue Service Caution: If you are claiming a net qualified disaster loss on Form 4684, see the instructions for line 16. Sequence No. 07
Name(s) shown on Form 1040 or 1040-SR Your social security number
MARY ELLEN OSWALD 047-56-3507
Medical Caution: Do not include expenses reimbursed or paid by others.
and 1 Medical and dental expenses (see instructions) . . . . . . . 1
Dental 2 Enter amount from Form 1040 or 1040-SR, line 11 2
Expenses 3 Multiply line 2 by 7.5% (0.075) . . . . . . . . . . . . . 3
4 Subtract line 3 from line 1. If line 3 is more than line 1, enter -0- . . . . . . . . . 4
Taxes You 5 State and local taxes.
Paid a State and local income taxes or general sales taxes. You may include
either income taxes or general sales taxes on line 5a, but not both. If
you elect to include general sales taxes instead of income taxes,
check this box . . . . . . . . . . . . . . . . . 5a 2,896.
b State and local real estate taxes (see instructions) . . . . . . . 5b 2,826.
c State and local personal property taxes . . . . . . . . . . 5c
d Add lines 5a through 5c . . . . . . . . . . . . . . . 5d 5,722.
e Enter the smaller of line 5d or $10,000 ($5,000 if married filing
separately) . . . . . . . . . . . . . . . . . . . 5e 5,722.
6 Other taxes. List type and amount:
6
7 Add lines 5e and 6 . . . . . . . . . . . . . . . . . . . . . . . 7 5,722.
Interest 8 Home mortgage interest and points. If you didn’t use all of your home
You Paid mortgage loan(s) to buy, build, or improve your home, see
Caution: Your instructions and check this box . . . . . . . . . . X
mortgage interest
deduction may be a Home mortgage interest and points reported to you on Form 1098.
limited. See See instructions if limited . . . . . . . . . . . . . . 8a 9,671.
instructions.
b Home mortgage interest not reported to you on Form 1098. See
instructions if limited. If paid to the person from whom you bought the
home, see instructions and show that person’s name, identifying no.,
and address . . . . . . . . . . . . . . . . . . . 8b

c Points not reported to you on Form 1098. See instructions for special
rules . . . . . . . . . . . . . . . . . . . . . 8c
d Reserved for future use . . . . . . . . . . . . . . . 8d
e Add lines 8a through 8c . . . . . . . . . . . . . . . 8e 9,671.
9 Investment interest. Attach Form 4952 if required. See instructions 9
10 Add lines 8e and 9 . . . . . . . . . . . . . . . . . . . . . . . . 10 9,671.
Gifts to 11 Gifts by cash or check. If you made any gift of $250 or more, see
Charity instructions . . . . . . . . . . . . . . . . . . . 11
Caution: If you 12 Other than by cash or check. If you made any gift of $250 or more,
made a gift and
got a benefit for it, see instructions. You must attach Form 8283 if over $500 . . . 12
see instructions. 13 Carryover from prior year . . . . . . . . . . . . . . 13
14 Add lines 11 through 13 . . . . . . . . . . . . . . . . . . . . . . 14
Casualty and 15 Casualty and theft loss(es) from a federally declared disaster (other than net qualified
Theft Losses disaster losses). Attach Form 4684 and enter the amount from line 18 of that form. See
instructions . . . . . . . . . . . . . . . . . . . . . . . . . . 15
Other 16 Other—from list in instructions. List type and amount:
Itemized
Deductions 16
Total 17 Add the amounts in the far right column for lines 4 through 16. Also, enter this amount on
Itemized Form 1040 or 1040-SR, line 12 . . . . . . . . . . . . . . . . . . . . 17 15,393.
Deductions 18 If you elect to itemize deductions even though they are less than your standard deduction,
check this box . . . . . . . . . . . . . . . . . . . . . . . .
For Paperwork Reduction Act Notice, see the Instructions for Form 1040. Cat. No. 17145C Schedule A (Form 1040) 2023

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 8889 Health Savings Accounts (HSAs) OMB No. 1545-0074

2023
Form
Attach to Form 1040, 1040-SR, or 1040-NR.
Department of the Treasury 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.
MARY ELLEN OSWALD 047-56-3507
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 2023.
See instructions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Self-only X Family
2 HSA contributions you made for 2023 (or those made on your behalf), including those made by the
unextended due date of your tax return that were for 2023. 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 2023 and, on the first day of every month during 2023, you
were, or were considered, an eligible individual with the same coverage, enter $3,850 ($7,750 for
family coverage). All others, see the instructions for the amount to enter . . . . . . . . . . 3 8,750.
4 Enter the amount you and your employer contributed to your Archer MSAs for 2023 from Form 8853,
lines 1 and 2. If you or your spouse had family coverage under an HDHP at any time during 2023, 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 8,750.
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 2023, see the instructions for the amount to enter . . 6 8,750.
7 If you were age 55 or older at the end of 2023, married, and you or your spouse had family coverage
under an HDHP at any time during 2023, enter your additional contribution amount. See instructions . 7
8 Add lines 6 and 7 . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8 8,750.
9 Employer contributions made to your HSAs for 2023 . . . . . . . . 9 1,083.
10 Qualified HSA funding distributions . . . . . . . . . . . . . . 10
11 Add lines 9 and 10 . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11 1,083.
12 Subtract line 11 from line 8. If zero or less, enter -0- . . . . . . . . . . . . . . . . . 12 7,667.
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.
14a Total distributions you received in 2023 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 8f . . . . . . . . . . . . . . 16
17a 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 8f . 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 (2023)

CDA