HSA Distribution Request and Account Closure Form

Submit the completed HSA Distribution Request Form by mailing it to PO Box 784, Fargo, ND 58107-0784. Alternatively, email the form to individualhsa@wexhealth.com or fax it to 877-765-8815. Ensure all sections are accurately filled out, the form is signed, and all required documentation is included. Double-check all addresses and information for new custodians to prevent any processing delays or returned checks. Advice: Always keep a copy of the submitted form and any correspondence for your records to address any discrepancies or follow-ups effectively.

Ensure all HSA Distribution Request Forms are submitted for processing before the tax deadlines: April 15, 2024, and April 15, 2025.

The primary purpose of this form is to facilitate the distribution of funds from a Health Savings Account (HSA) or to request the closure of an HSA account. Whether you need to remove excess contributions, rollover funds to another account, or address specific life changes such as divorce or disability, this form provides the necessary sections to accommodate various distribution types. By completing and submitting the form along with any required additional documentation, you ensure that your HSA funds are correctly distributed or transferred as needed. This form is also crucial for beneficiaries who need to manage HSA funds after the accountholder's death. Detailed instructions and fields are provided to capture all necessary information for proper tax reporting and distribution processing. Adherence to the guidelines and accurate completion of each section will prevent delays or complications in handling your HSA funds. Using this form through PrintFriendly offers the added convenience of online editing and signing. This allows for a streamlined process, ensuring your distribution request is completed efficiently and accurately, ready for submission to the appropriate custodian or authority.

• 1. Employer Name: Provide your employer's name without any abbreviations.
• 2. Accountholder Name: Enter the full name of the HSA accountholder, including first name, middle initial, and last name.
• 3. Physical Address: State the complete physical address of the accountholder; PO Boxes are not accepted.
• 4. Day Telephone: Provide a daytime telephone number where you can be reached.
• 5. Employee ID Number: Include your employee identification number if applicable.
• 6. Social Security Number: Provide the accountholder’s Social Security Number.
• 7. City, State, Zip: Enter the city, state, and zip code associated with the physical address.
• 8. Requested Amount: Specify the amount you are requesting for distribution from your HSA.
• 9. Distribution Type: Select the type of distribution: Normal, Excess Contribution Removal, Rollover, Transfer, Disability, Divorce, Prohibited Transaction, or Mistaken Contribution.
• 10. Excess Contribution Details: If applicable, provide the date the excess contribution occurred.
• 11. New Custodian Information: For transfers, provide the new custodian's name, address, and account number.
• 12. Accountholder Signature: The accountholder must sign the form to certify the provided information is true and correct.
• 13. Date: Include the date when the form is signed.

Failure to submit this form may delay or prevent the distribution of your HSA funds, potentially resulting in additional taxes or penalties. It's essential to complete and submit the form promptly to ensure proper handling of your HSA.

• Delayed Distribution: Failure to submit the form will result in delayed processing of your HSA funds request.
• Additional Taxes: Not properly documenting distributions may lead to additional taxes and penalties from the IRS.
• Account Closure Issues: Your HSA account may remain open if the closure form is not submitted, leading to continuing fees.

• 1. Requesting Distribution: When you need to withdraw funds from your HSA for any eligible reason.
• 2. Closing HSA Account: When you wish to close your HSA account entirely and receive the final balance.
• 3. Excess Contribution Removal: If you've contributed more than the allowable limit to your HSA and need to correct it.
• 4. Rollover to New Custodian: Transferring HSA funds to another HSA custodian requires this form.
• 5. Distribution Due to Life Event: Events like disability, divorce, or a prohibited transaction necessitate using this form.