Form Gc 1565 PDF Details

Form Gc 1565 is a tax form used by taxpayers to report information about foreign financial accounts. The form was introduced in 2015 as part of the Foreign Account Tax Compliance Act (FATCA). The purpose of FATCA is to crack down on tax evasion by U.S. taxpayers with offshore accounts. Form Gc 1565 must be filed by June 30th each year, regardless of whether or not you have any foreign financial accounts. In order to complete the form, you will need your bank's name, address, and contact information; the account numbers for each foreign financial account; and the maximum balance for each account during the year. If you have any questions about completing Form Gc 1565, please consult your tax advisor.

You'll discover details about the type of form you intend to submit in the table. It can tell you the time you will require to finish form gc 1565, exactly what parts you will have to fill in and some other specific details.

Form NameForm Gc 1565
Form Length1 pages
Fillable fields0
Avg. time to fill out15 sec
Other namescertify, HSA-03, GC-1565, Custodial

Form Preview Example

Health Savings Account

With HSA Debit Card

Request To Rollover/Transfer Funds To Health Savings Account

Chase Health Savings Account #: 397_ _ _ _ _ _ _ _ _

Account Holder Name: _______________________, ____________________, _____





Mailing Address:






Apt. #:






Zip Code:




Daytime Telephone #: ___________________ SS#: ______ - _____ - ___________

Rollover Instructions:

Account holders may rollover funds from an existing Health Savings Account (HSA) or Medical Savings Account (MSA) at another institution into their HSA. By using this form, you certify to Chase that the attached funds are an eligible rollover contribution.

To rollover funds, request a distribution from your current MSA or HSA, then complete the information requested and sign this form. Send the completed form with a check made payable to “JPMorgan Chase Bank, N.A in the account of <Your Name>” to JPMorgan Chase Bank, N.A., HSA Operations, P.O. Box 30207, Tampa, FL 33630-3207.

Trustee-to-Trustee Transfers:

Account holders may advise their current HSA custodian to transfer funds to their new HSA by completing the following information and providing it to their current HSA custodian:

Please transfer all funds in my account listed below to my Health Savings Account.

Account Type (check one):

Medical Savings Account (MSA)

Health Savings Account (HSA)

Account #:



Custodial Institution Name:


Institution Address:




State: ___________

Zip Code:



Send the proceeds of the HSA in a check made payable to “JPMorgan Chase Bank, N.A. in the account of <Your Name>” to:

JPMorgan Chase Bank, N.A. HSA Operations

P.O. Box 30207 Tampa, FL 33630-3207

Along with the check, please include this form or other correspondence including the account holder’s name, Social Security Number, and a confirmation that this is a HSA (or MSA) trustee-to-trustee transfer.

Authorization to Transfer Funds:

Account Holder’s Signature _________________________________ Date: _______________

Please be advised, we may verify the account holder’s signature.

For questions about rollovers or trustee-to-trustee transfers, please contact HSA Member Services at 866-524-2483.

HSA-03 09/01/05


GC-1565 (3-06)


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