Form 8959
Department of the Treasury
Internal Revenue Service
Additional Medicare Tax
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If any line does not apply to you, leave it blank. See separate instructions.
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Attach to Form 1040, 1040-SR, 1040-NR, 1040-PR, or 1040-SS.
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Go to www.irs.gov/Form8959 for instructions and the latest information.
OMB No. 1545-0074
2019
Attachment
Sequence No.
71
Name(s) shown on return Your social security number
Part I Additional Medicare Tax on Medicare Wages
1 Medicare wages and tips from Form W-2, box 5. If you have more than one
Form W-2, enter the total of the amounts from box 5 . . . . . . . . 1
2 Unreported tips from Form 4137, line 6 . . . . . . . . . . . . . 2
3 Wages from Form 8919, line 6 . . . . . . . . . . . . . . . . 3
4 Add lines 1 through 3 . . . . . . . . . . . . . . . . . . . 4
5 Enter the following amount for your filing status:
Married filing jointly . . . . . . . . . . . . . . . $250,000
Married filing separately . . . . . . . . . . . . . . $125,000
Single, Head of household, or Qualifying widow(er) . . . . . $200,000 5
6 Subtract line 5 from line 4. If zero or less, enter -0- . . . . . . . . . . . . . . . . . 6
7 Additional Medicare Tax on Medicare wages. Multiply line 6 by 0.9% (0.009). Enter here and go to
Part II . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
7
Part II Additional Medicare Tax on Self-Employment Income
8
Self-employment income from Schedule SE (Form 1040 or 1040-SR), Section
A, line 4, or Section B, line 6. If you had a loss, enter -0- (Form 1040-PR or
1040-SS filers, see instructions.) . . . . . . . . . . . . . . .
8
9 Enter the following amount for your filing status:
Married filing jointly. . . . . . . . . . . . . . . . $250,000
Married filing separately . . . . . . . . . . . . . . $125,000
Single, Head of household, or Qualifying widow(er) . . . . . $200,000 9
10 Enter the amount from line 4 . . . . . . . . . . . . . . . . 10
11 Subtract line 10 from line 9. If zero or less, enter -0- . . . . . . . . . 11
12 Subtract line 11 from line 8. If zero or less, enter -0- . . . . . . . . . . . . . . . . . 12
13 Additional Medicare Tax on self-employment income. Multiply line 12 by 0.9% (0.009). Enter here and
go to Part III . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
13
Part III Additional Medicare Tax on Railroad Retirement Tax Act (RRTA) Compensation
14 Railroad retirement (RRTA) compensation and tips from Form(s) W-2, box 14
(see instructions) . . . . . . . . . . . . . . . . . . . . 14
15 Enter the following amount for your filing status:
Married filing jointly . . . . . . . . . . . . . . . $250,000
Married filing separately . . . . . . . . . . . . . . $125,000
Single, Head of household, or Qualifying widow(er) . . . . . $200,000 15
16 Subtract line 15 from line 14. If zero or less, enter -0- . . . . . . . . . . . . . . . . 16
17 Additional Medicare Tax on railroad retirement (RRTA) compensation. Multiply line 16 by 0.9% (0.009).
Enter here and go to Part IV . . . . . . . . . . . . . . . . . . . . . . . . .
17
Part IV Total Additional Medicare Tax
18 Add lines 7, 13, and 17. Also include this amount on Schedule 2 (Form 1040
or 1040-SR),
line 8 (check
box a) (Form 1040-NR, 1040-PR, or 1040-SS filers, see instructions), and go to Part V . . . . .
18
Part V Withholding Reconciliation
19 Medicare tax withheld from Form W-2, box 6. If you have more than one Form
W-2, enter the total of the amounts from box 6 . . . . . . . . . . 19
20 Enter the amount from line 1 . . . . . . . . . . . . . . . . 20
21 Multiply line 20 by 1.45% (0.0145). This is your regular Medicare tax
withholding on Medicare wages . . . . . . . . . . . . . . . 21
22 Subtract line 21 from line 19. If zero or less, enter -0-. This is your Additional Medicare Tax
withholding on Medicare wages . . . . . . . . . . . . . . . . . . . . . . .
22
23 Additional Medicare Tax withholding on railroad retirement (RRTA) compensation from Form W-2, box
14 (see instructions) . . . . . . . . . . . . . . . . . . . . . . . . . . . 23
24
Total Additional Medicare Tax withholding. Add lines 22 and 23. Also include this amount with
federal income tax withholding on Form 1040 or 1040-SR, line 17 (Form 1040-NR, 1040-PR, or
1040-SS filers, see instructions) . . . . . . . . . . . . . . . . . . . . . . .
24
For Paperwork Reduction Act Notice, see your tax return instructions.
Cat. No. 59475X
Form 8959 (2019)
