Form Hsa 02 – Fill Out and Use This PDF

Form Hsa 02 is a record of contributions made by an employer to your health savings account, Archer MSA or Medicare Advantage MSA.

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Form Hsa 02 PDF Details

Form Hsa 02 is a form that is used to report the sale or exchange of certain property. This form is used to report the sale or exchange of depreciable and nondepreciable personal property, other than inventory and stocks, for which you received a Form 1099-B, Proceeds From Broker and Barter Exchange Transactions. You must also use this form to report any gain or loss on the sale or exchange of patents, copyrights, commodities contracts, and foreign currency transactions. This form must be filed by the due date for your income tax return, including extensions. For more information about Form Hsa 02 and its requirements, please consult your tax advisor.

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Question	Answer
Form Name	Form Hsa 02
Form Length	2 pages
Fillable?	Yes
Fillable fields	82
Avg. time to fill out	16 min 54 sec
Other names	how to change beneficiary on chase bank account, jpmorgan chase beneficiary forms, how to add beneficiary to chase bank account, how to add beneficiary to chase bank account online

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Health Savings Account

With HSA Debit Card

Designation of Beneficiary for Health Savings Account

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

Account Holder Name: __________________________, _______________________, _____

	(Last)	(First)	(MI)
Mailing Address:
Street:	_______________________________________________________
Apt. #:	_______________________________________________________
City:	________________________	State: ___________
Zip Code:	__________-_____________

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

Beneficiary Designation

Please list one or more primary beneficiaries for your Health Savings Account (HSA) referenced above or any successor to this HSA, indicating the beneficiary percentage that should be provided to each primary beneficiary in the event of your death (the percentages should add to 100%). If a primary beneficiary should predecease you, his or her interest, as well as the interests of his or her heirs, will terminate completely and the percentage share of the surviving primary beneficiaries will be increased on a pro-rata basis. If you do not designate beneficiaries, or if the total percentage designated for your beneficiaries is less than 100% of your HSA, the remaining HSA funds will become part of your estate after your death. Please refer to your Health Savings Custodial Account Agreement for more detailed provisions regarding beneficiaries. This beneficiary designation is effective upon receipt by Chase and unless otherwise specified cancels all previous designations on file with Chase.

Primary Beneficiary 1

Name:	___________________________	Relationship:	_________________________
Address:	______________________	Social Security #	_______ -	____ - _______
	______________________
City:	___________________________	State, Zip Code	_______	_________ - ______
Telephone #:	___________________________	Beneficiary %	_______

Primary Beneficiary 2

Name:	___________________________	Relationship:	_________________________
Address:	______________________	Social Security #	_______ -	____ - _______
	______________________
City:	___________________________	State, Zip Code	_______	_________ - ______
Telephone #:	___________________________	Beneficiary %	_______

Primary Beneficiary 3

Name:	___________________________	Relationship:	_________________________
Address:	______________________	Social Security #	_______ -	____ - _______
	______________________
City:	___________________________	State, Zip Code	_______	_________ - ______
Telephone #:	___________________________	Beneficiary %	_______

HSA-02 09/20/06

Health Savings Account

With HSA Debit Card

Designation of Beneficiary for Health Savings Account, continued

Contingent beneficiaries will receive your HSA assets in the event that all of your primary beneficiaries predecease you. Please list one or more contingent beneficiaries, together with the percentage of your HSA assets that each should receive (the percentages you list for all contingent beneficiaries should sum to 100%).

Contingent Beneficiary 1

Name:	___________________________	Relationship:	_________________________
Address:	______________________	Social Security #	_______ -	____ - _______
	______________________
City:	___________________________	State, Zip Code	_______	_________ - ______
Telephone #:	___________________________	Beneficiary %	_______

Contingent Beneficiary 2

Name:	___________________________	Relationship:	_________________________
Address:	______________________	Social Security #	_______ -	____ - _______
	______________________
City:	___________________________	State, Zip Code	_______	_________ - ______
Telephone #:	___________________________	Beneficiary %	_______

SPOUSAL CONSENT:

Your spouse’s signature is required below if you are married, have your legal residence in any community or marital property state (Arizona, California, Idaho, Louisiana, Nevada, New Mexico, Texas, Washington or Wisconsin) and you have designated someone other than, or in addition to, your spouse as beneficiary. If you do not obtain your spouse’s signature, you warrant none is required:

X__________________________________________________	_________________
Spouse’s Signature	Date Signed
____________________________________________________
Print Name

Please forward this completed form to:

JPMorgan Chase Bank, N.A.

HSA Operations

P.O. Box 30207

Tampa, FL 33630-3207

For questions about account beneficiary matters, please contact HSA Member Services at 866-524-2483.

X	_____
Signature of Account Holder			Date Signed

HSA-02 09/20/06

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