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I understand that Chase will wait 10 days to allow any outstanding debit card transactions to settle before mailing the check for any remaining account balance less any applicable Account Closing fee. OPTION 1 Trustee-to-Trustee Transfer Account holders may instruct Chase to transfer funds from their HSA at Chase to their new HSA at another institution by completing the information below. Health Savings Account With HSA Debit Card Request to Close Health Savings Account Complete and return this form to Chase after all outstanding checks written on your Health Savings Account HSA have been paid. Once Chase receives your completed form the account closure process begins and any HSA checks presented for payment will not be honored. If your employer sends contributions to your HSA be sure to notify your employer to stop all further contributions. If you have opened an HSA Investment Account you must contact J*P. Morgan Institutional Investments Inc* JPMII at 866-774-7129 to request liquidation of your investments and closure of the Investment Account prior to returning this form* If your HSA Investment Account has a zero balance you hereby instruct JPMII to close the Investment Account. The HSA cash account cannot be closed until the investments have been liquidated* Account Holder Name Last First MI Mailing Address Street Apt. City State Zip Code - Last 4 digits of your SS Note If this does not match the address we have on file it will cause a delay in closing your account. Daytime Telephone Please close my Health Savings Account and disburse the funds as directed below. I understand that Chase will wait 10 days to allow any outstanding debit card transactions to settle before mailing the check for any remaining account balance less any applicable Account Closing fee. OPTION 1 Trustee-to-Trustee Transfer Account holders may instruct Chase to transfer funds from their HSA at Chase to their new HSA at another institution by completing the information below. Please transfer the funds in my HSA listed above to my new Health Savings Account at the institution listed below. Make the check payable to the new custodial institution and forward it directly to them* Custodial Institution Name Institution Address City Zip Code Account Mellon HSA Solution PO Box 4038 Woburn 01888-4038 OPTION 2 Rollover or Direct Distribution to Account Holder You may roll over funds from this HSA to an HSA at another institution* Note To qualify as a rollover any amount paid or distributed from an HSA to an account holder must be paid over to an HSA within 60 days after the date of receipt of the payment or distribution* Please send me a check for the funds in my account. For any questions about closing your HSA please contact HSA Member Services at 866-524-2483. Forward this form to JPMorgan Chase Bank N*A. HSA Operations P. O. Box 30207 Tampa FL 33630-3207. HSA-06 12/19/06 Please be advised we may verify the account holder s signature. If you have opened an HSA Investment Account you must contact J*P. Morgan Institutional Investments Inc* JPMII at 866-774-7129 to request liquidation of your investments and closure of the Investment Account prior to returning this form* If your HSA Investment Account has a zero balance you hereby instruct JPMII to close the Investment Account. The HSA cash account cannot be closed until the investments have been liquidated* Account Holder Name Last First MI Mailing Address Street Apt.

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