Hsa Contribution Coupon Form PDF Details

The HSA Contribution Coupon form serves as a structured channel for accountholders to make contributions to their Health Savings Account (HSA) in an organized and official manner. This document, updated in June 2012, delineates a clear, step-by-step procedure for submitting contributions, which can be personal, from an employer, or other types such as rollovers from another HSA or Medical Savings Account (MSA), re-deposits of previously withdrawn funds, or contributions for the prior tax year if made within a specific timeframe. Accountholders are instructed to provide their name, specify the contribution amount, and select the type of contribution, if other than a personal contribution for the current tax year, before submitting their account number. The necessity of using only black or blue ink for filling out the form underscores the importance of legibility and official record-keeping. The final steps involve printing the form, separating it at the indicated dotted line, and mailing it to the UMB HSA Processing center located in Kansas City, Missouri. By laying down these guidelines, the form not only facilitates a smooth transaction process for HSA contributions but also ensures compliance with tax regulations and promotes financial planning and organization among accountholders.

QuestionAnswer
Form NameHsa Contribution Coupon Form
Form Length1 pages
Fillable?No
Fillable fields0
Avg. time to fill out15 sec
Other namesAccountholder, Remit, HSA, contribution form template

Form Preview Example

(R 06/12)

Follow these steps to complete the form online.

Step 1. Enter the Accountholder’s name.

Step 2. Enter the check contribution amount.

Step 3. Check the type of contribution.

If you are making a personal contribution for the current tax year, you are not required to check any of the contribution type boxes. Proceed to Step 4.

Prior Year Contribution – You may select to have your contribution deposited under the prior plan year if your contribution falls between Jan 1 and Apr 15th and you

have not paid this year’s taxes.

Employer Contribution – Any amount contributed by your employer.

Re-Deposit Amount– Adding money mistakenly withdrawn from your HSA back into the account.

Rollover or Transfer Contribution – Contribution of money moved from another MSA or HSA.

Step 4: Enter Your

Health Savings

Account number.

Step 5: Print slips and separate on the dotted line.

Step 6: Mail to

UMB HSA Processing P.O. Box 219531 Kansas City, MO 64121-9531

HSA CONTRIBUTION COUPON

USE ONLY BLACK OR BLUE INK.

Accountholder’s Name:

Please Enter Check Amount Enclosed:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

.

 

 

 

 

Please Remit to:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

UMB HSA Processing

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

P.O. Box 219531

 

 

 

 

 

Kansas City, MO 64121-9531

 

 

 

 

 

If applicable, place an X in ONE of these boxes:

 

USE ONLY BLACK OR BLUE INK.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

1 Prior Year

 

 

 

 

 

2 Employer

 

 

 

 

 

3 Re-Deposit

 

 

 

 

 

 

4 Rollover

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Account Number:

HSA CONTRIBUTION COUPON

USE ONLY BLACK OR BLUE INK.

Accountholder’s Name:

Please Enter Check Amount Enclosed:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Please Remit to:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

UMB HSA Processing

 

 

 

 

 

P.O. Box 219531

 

 

 

 

 

Kansas City, MO 64121-9531

 

 

 

 

 

If applicable, place an X in ONE of these boxes:

 

USE ONLY BLACK OR BLUE INK.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

1 Prior Year

 

 

 

 

 

2 Employer

 

 

 

 

 

3 Re-Deposit

 

 

 

 

 

 

4 Rollover

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Account Number:

HSA CONTRIBUTION COUPON

USE ONLY BLACK OR BLUE INK.

Account holder’s Name:

Please Enter Check Amount Enclosed:

.

 

Please Remit to:

UMB HSA Processing

P.O. Box 219531

Kansas City, MO 64121-9531

If applicable, place an X in ONE of these boxes:

 

 

USE ONLY BLACK OR BLUE INK.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

1 Prior Year

 

 

 

 

2 Employer

 

 

 

 

 

3 Re-Deposit

 

 

 

 

 

4 Rollover

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Account Number:

How to Edit Hsa Contribution Coupon Form Online for Free

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Step 1: Open the form in our editor by clicking on the "Get Form Button" at the top of this page.

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This PDF form needs some specific information; to ensure accuracy and reliability, you need to heed the tips just below:

1. Fill out your HSA with a group of major blanks. Gather all the information you need and make sure not a single thing missed!

Tips to prepare generic hsa enrollment form part 1

2. Just after completing this part, head on to the next part and fill out all required details in these fields - ReDeposit Amount, Adding money mistakenly withdrawn, Rollover or Transfer, Contribution Contribution of, Step Enter Your Health Savings, Step Print slips and separate on, Step Mail to UMB HSA Processing, Account holders Name, Please Remit to UMB HSA Processing, Please Enter Check Amount Enclosed, If applicable place an X in ONE of, Employer, Account Number, USE ONLY BLACK OR BLUE INK, and ReDeposit.

Rollover or Transfer, Step Print slips and separate on, and If applicable place an X in ONE of inside generic hsa enrollment form

Be really careful when completing Rollover or Transfer and Step Print slips and separate on, since this is the part in which many people make a few mistakes.

Step 3: Be certain that your details are correct and simply click "Done" to progress further. Join us right now and easily use HSA, all set for downloading. All alterations made by you are saved , letting you modify the pdf at a later time when necessary. FormsPal provides safe form tools without personal data recording or any sort of sharing. Be assured that your information is safe here!

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