Get Hsa Distribution Request Form - Bruce Fund

The HSA Distribution Request Form for the Bruce Fund is essential for users requesting distributions from their Health Savings Account (HSA). This guide provides clear instructions to help you successfully complete the form online, ensuring that all necessary information is accurately gathered.

Follow the steps to complete your distribution request form effectively.

1. Press the ‘Get Form’ button to acquire the form and access it in your preferred online editor.
2. Part I: HSA Owner Information. Fill in your full name as required, including date of birth and social security number. Be sure to provide your complete physical address, including street address, city, state, zip code, and apartment number, if applicable.
3. Also in Part I, fill in your daytime phone number and HSA account or plan number as these fields are necessary for processing your request.
4. Part II: Distribution Information. Indicate who is requesting the distribution by choosing 'HSA Owner,' 'Authorized Signer,' or 'Beneficiary.' Select the distribution reason from the options: 'Normal,' 'Disability,' 'Death,' 'Prohibited Transaction,' or 'Transfer.' If transferring, specify the destination account.
5. Provide details regarding the relationship to the HSA owner, including whether you are a spouse or non-spouse, and include the year of the owner's death if applicable.
6. Specify the excess contribution amount and earnings attributable to the excess if relevant, as instructed in this section.
7. Part III: Distribution Instructions. Indicate the amount for the distribution and the frequency (e.g., single distribution, monthly, quarterly). Specify the name of the investment and the beginning date for withdrawals.
8. Part IV: Payment Instructions. Choose how you would like to receive payment, whether by mail or to an alternative payee. Fill in necessary details for additional payment addresses where required.
9. Part V: Acknowledgement and New Technology Medallion Signature Guarantee. Sign and date the form to certify the accuracy of the information provided, and ensure that an authorized signature is included according to the guidelines.
10. Once you have completed all sections of the form, you can save your changes, download, print, or share it as needed.

Complete your HSA Distribution Request Form online today to ensure timely processing of your request.