Form Hsa 014 – Fill Out and Use This PDF

Account Holder Name: HSA Account No.:

Home Address:

City:			State:			Zip:
Telephone No.:			Social Security No.:			Date of Birth:

B METHOD OF DISTRIBUTION

Please select one:

Total distribution of my entire account and close account.

 Partial distribution of $ (Tell us what to sell in “OTHER” if insufficient cash.) Excess contribution (Please complete Section D.)

Re-register all assets in my name and send them to me along with the total cash balance in my account.

OTHER: (e.g. name of asset, number of shares, tell us if the asset should be sold or re-registered, etc.)

Asset Name		No. Shares/Dollar Amt.		Sell or Re-Register

(All distributions will be reported to the IRS on Form 1099-SA.)

C PAYMENT DELIVERY

Checks will be sent to you via U.S. Mail unless overnight delivery is requested.

Wire funds - Please complete banking information below. (Signature Guarantee required - Section E.)

A $25 wire fee applies. Please ensure the accuracy of your financial institution’s wire instructions. If a wire is rejected due to the incorrect wire instructions, an additional $25 will be charged.

Banking Information:

Bank Name:

Bank Address:

City:				State:			Zip:
ABA Routing No.:				Bank Account No.:
Name on Bank Account:

Please continue to page two to complete this form.

HSA-014 *HSA-014*

07-10

HSA MANAGER DISTRIBUTION REQUEST, Page 2 of 2

D EXCESS CONTRIBUTION

Excess contributions for: (Indicate year)

$ Excess Contribution Amount: Must be withdrawn by IRS tax filing deadline, including extensions,

and indicated on your tax return for the year the contribution was made.

$		Excess Earnings Removed: Income earned on contribution must be included as “Other
		Income” on your tax return for the year the earnings are withdrawn.

Generally, you must pay a 6% excise tax on contributions. See IRS Form 5329 to figure the excise tax, if necessary.

E RECIPIENT’S ACKNOWLEDGEMENT AND SIGNATURE

Applicable fees are payable in accordance with the Custodial Agreement and will be deducted from the account unless you remit the amount due.

Please make the above-referenced distribution. I have consulted my tax advisor concerning the taxable effect of the requested distribution and agree to be fully responsible for the same.

[Signature Guarantee Stamp Here]

Account Holder Signature

Date:

HSA-014

07-10