The HSA-06 form is an essential document for individuals wishing to close their Health Savings Account (HSA) with Chase. The process requires account holders to ensure all outstanding checks have been cleared before submission. Upon receiving the completed form, Chase initiates the account closure, and it will no longer honor any HSA checks presented afterward. It's crucial for individuals to inform their employers to halt any further contributions to the HSA. Those with an associated HSA Investment Account must contact J.P. Morgan Institutional Investments, Inc. to facilitate the liquidation of investments and closing of the investment account as part of the procedure. Account holders are provided with instructions to direct the disbursement of remaining funds, either by transferring them to a new HSA trustee or by receiving them directly through various payout options. This form not only represents the end of an HSA with Chase but also outlines the necessary steps and options for account holders, ensuring a seamless transition of funds according to their future financial planning needs.
| Question | Answer |
|---|---|
| Form Name | Form Hsa 06 |
| Form Length | 2 pages |
| Fillable? | No |
| Fillable fields | 0 |
| Avg. time to fill out | 30 sec |
| Other names | close_account aetna health savings account chase form |
|
|
|
Request to Close Health Savings Account
Complete and return this form to Chase after all outstanding checks written on the Health Savings Account (HSA) have been paid. Once Chase receives your completed form, the account closure process begins, and any HSA checks presented for payment will not be honored. If applicable, be sure to notify your employer to stop all further contributions to your HSA.
If you have opened an HSA Investment Account, you must contact J.P. Morgan Institutional Investments, Inc. (JPMII) at
Account Information and Mailing Address:
Last 9 Digits of the Health Savings Account #: xxx _ _ _ _ _ _ _ _ _
First Name: _________________________ M.I. ___ Last Name___________________________________
Daytime Telephone #: (_____)____________ |
Last 4 digits of your SS#: ___________________ |
|||
Street: |
_______________________________________________________________________________ |
|||
Apt #: |
_____________________________ |
|
|
|
|
|
|
Zip |
|
City: |
____________________________ |
State: ___________ |
Code: |
______________ |
If this may not match the address we have on file, please provide your month, day, and year of birth here: _____________.
Account Holder Request and Authorization to Close Health Savings Account
Please close my Health Savings Account and disburse the funds as directed below. I understand that Chase will wait 10 days to allow any outstanding debit card transactions to settle before mailing the check for any remaining account balance less any applicable Account Closing fee.
Account Holder’s Signature _________________________________ |
Date: _______________ |
Funds Disbursement Option 1: HSA
You may instruct Chase to transfer funds from your Chase HSA to a new HSA at another institution by completing the information below.
Please transfer the funds in my HSA listed above to my new Health Savings Account at the institution listed below. Make the check payable to the new custodial institution and forward it directly to them.
Custodial Institution Name: |
_______________________________________________________ |
|
Institution Address: |
_______________________________________________________ |
|
City: |
________________________ |
State: ___________ |
Zip Code: |
|
|
Account #: |
________________________ |
|
Please see additional instructions on page 2 about where to send your completed form.
Page 1 of 2 |
Mutual funds are introduced by, and HSA investment accounts are offered by J.P. Morgan institutional
Investments Inc., member FINRA and SIPC, and an affiliate of JPMorgan Chase Bank, N.A.
Request to Close Health Savings Account, continued
Funds Disbursement Option 2: Rollover or Direct Distribution to Account Holder
You may instruct Chase to send you the funds from your HSA. You may then choose to roll over these funds to an HSA at another institution. Note: To qualify as a rollover, any amount paid or distributed from an HSA to an account holder must be paid over to an HSA within 60 days after the date of receipt of the payment or distribution.
Please send me a check for the funds in my account.
Payout Options: (Select one.)
Please send the funds directly to my checking account via electronic funds transfer (EFT). Please send me a check for the funds in my account.
Funds Disbursement Method
Chase will process your request within three business days after receipt of a completed, signed copy of this form and will disburse funds as follows:
•Funds you have instructed Chase to send by check will be sent to the address provided within 4 business days after the account closure.
•If you have instructed Chase to send an electronic funds transfer (“EFT”) to your personal checking account, please attach a voided check below so we have the required information for completing the transfer. The checking account must be in the name of the same individual as the HSA. If these requirements are not met, then funds will instead be sent by check.
PLEASE ATTACH VOIDED CHECK HERE
(simply write “VOID” across a check)
Next Steps
Forward your completed form to:
JPMorgan Chase Bank, N.A.
HSA Operations
P.O. Box 30207
Tampa, FL
For any additional questions regarding the closure of your HSA, please contact HSA Member Services at
Page 2 of 2 |
Mutual funds are introduced by, and HSA investment accounts are offered by J.P. Morgan institutional
Investments Inc., member FINRA and SIPC, and an affiliate of JPMorgan Chase Bank, N.A.