Follow the steps to complete the HSA Fax Form.

1. Click ‘Get Form’ button to obtain the form and open it in your editor.
2. In the personal information section, fill in the required fields. Start with your first name, middle name, last name, account number, mailing address, city, state, email, phone, alternate phone, and zip code. Ensure all the required fields are completed accurately.
3. In the contribution section, provide the current tax year for which you are making a contribution and indicate the amount you wish to contribute. Be mindful that contributions for prior tax years can be submitted until the federal income tax return deadline.
4. Next, enter the prior tax year and its corresponding contribution amount. Again, ensure this information is accurate to avoid any issues with your contribution.
5. Review the certification statement, confirming that you accept responsibility for any tax consequences related to your contribution. This is important for compliance and record-keeping.
6. Sign and date the form in the designated areas to complete the completion of the form.
7. Finally, save your changes, download the completed form, print it, and mail it, along with your payment method, to the specified address: Wells Fargo Health Benefit Services, P.O. Box 45600, Salt Lake City, UT 84145-0600.

Get started now to complete your contribution documents online.