Advanced Scenario 3: Rose Jones Interview Notes . Rose Jones, age 57, is single. . Rose earned wages of $52,000 and was enrolled the entire year in a high deductible health plan (HD with self-only coverage. . During the year, Rose contributed $2,000 to her Health Savings Account (HSA) and her mother also contributed $1,000 to Rose's HSA. . Rose's Form W-2 shows $850 in Box 12 with code W. She has Form 5498-SA showing $3,850 in Bo . Rose took a distribution from her HSA to pay her unreimbursed expenses: o 8 visits to a physical therapist after her knee surgery $400 o unreimbursed doctor bills for $1, 100 . prescription medicine $280 o replacement of a crown $1,500 o deep cleaning for teeth: $300 o over the counter medication $40 o gym membership $240 . Rose is a U.S. citizen with a valid Social Security number. Advanced Scenario 3: Test Questions 6. Form 8889, Part 1 is used to report HSA contributions made by a. Rose b. Rose's employer c. Rose's mother d. All of the above 7. Rose is eligible to contribute an additional $ to her HSA because she is age 55 or olde a. $0 b. $850 c. $1,000 d. $2,000