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Get Health Savings Account Mistaken Distribution Form

Ution was the result of a mistake of fact and I authorize the Custodian/Trustee to redeposit the distribution as a mistaken distribution. I understand the Custodian/Trustee is not required to accept the mistaken distribution and I am responsible for any tax consequence that may result from the distribution. SIGNATURES By my signature below I certify that this deposit to my Health Savings Account, in the amount stated above, is repayment of a mistaken distribution or distributions as defined by t.

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