Wells Fargo Form Hsa Ecf – Fill Out and Use This 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 84145-0600

Contact Information

Last Name	First Name	M.I.	Social Security #	Date of Termination
Street Address			City	State	Zip
E-Mail Address			Home Phone # (area code)	Work Phone # (with area code & ext.)

Distribution Options

Your employer-sponsored HSA ends upon termination of employment. For your convenience, Wells Fargo will automatically roll any outstanding balances into an individual HSA. However, you may choose another distribution option by selecting from one of the following:

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	City	State	Zip

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 non-medical expense will be taxable and reportable on my individual tax return, and a 10% excise tax may be due unless an exception applies under IRS regulations. I certify that I have filled out this form completely, and wish to close my current HSA.

Signature of Account Holder	Date of Application

Web site: https://healthbenefits.wellsfargo.com

Phone: (866) 890-8309

HSA-ECF 3/15/2006