When employees leave their job, managing funds tied to employer-sponsored benefit plans can seem daunting. This is particularly true for Health Savings Accounts (HSAs), which are designed to offer individuals a tax-advantaged way to pay for qualified medical expenses. The Wells Fargo HSA Closure Form plays a critical role in this transition, providing a structured process for employees to close their HSAs upon termination of employment. Mailed to Wells Fargo Health Benefit Services, it requires detailed information, including the account holder's personal details and preferences for the distribution of remaining funds. Options include having a check sent for the account balance, directing the funds to another financial institution, or rolling the balance into an individual HSA, which Wells Fargo will do automatically if no other selection is made. Additionally, the form addresses account closures due to the death of the owner, disability, or reaching age 65, highlighting the importance of navigating post-employment benefits with care. By completing this form, an individual can ensure their HSA is handled according to their wishes, providing peace of mind during a period of transition. Through a signature, the account holder acknowledges the closure of their HSA in alignment with the Health Savings Account Disclosure and Custodial Account Agreement, also acknowledging potential tax implications for non-medical withdrawals in keeping with IRS regulations. The form reflects an understanding of the complexities associated with healthcare savings and provides a necessary tool for individuals as they navigate changes in employment and associated benefits.
| Question | Answer |
|---|---|
| Form Name | Wells Fargo Form Hsa Ecf |
| Form Length | 1 pages |
| Fillable? | No |
| Fillable fields | 0 |
| Avg. time to fill out | 15 sec |
| Other names | lodge bill format, lodge receipt format, lodge bill format pdf no download needed, lodge bill format in pdf |
Health Savings Account (HSA) Closure Form for Employees
Please mail completed form to:
Wells Fargo Health Benefit Services, P.O. Box 45600, Salt Lake City, UT
Contact Information
Last Name |
First Name |
M.I. |
Social Security # |
Date of Termination |
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Street Address |
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State |
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Home Phone # (area code) |
Work Phone # (with area code & ext.) |
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Distribution Options
Your
Please send me a check for the remaining balance of my account after all fund investments have been liquidated. If I have elected Direct Deposit for claim reimbursements, then funds will be deposited into my account.
Please roll my balances into an HSA with another financial institution. A check payable to myself and my new financial institution will be mailed directly to the financial institution at the address below.
Name of Financial Institution
Street Address of Financial Institution |
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State |
Zip |
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Account Owner Status
Please select one of the following options.
Death of Owner
Disabled
Age 65 or Older
None Apply
I hereby request that Wells Fargo Health Benefit Services close my Health Savings Account (HSA). I acknowledge that this account will be closed according to the Health Savings Account Disclosure and Custodial Account Agreement.
I certify that under my HSA any
Signature of Account Holder |
Date of Application |
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Web site: https://healthbenefits.wellsfargo.com
Phone: (866)