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Get Health Savings Account Distribution Form Fillable Form

E PHONE NUMBER E-MAIL (OPTIONAL) DISTRIBUTION REASON DATE OF BIRTH DATE OF DEATH (IF APPLICABLE) (For further information, see Additional Information included with this form.) Select One. l Normal l Death Type of Beneficiary: l Spouse l Estate l Other Distribution is in: l Year of Death l After Year of Death Fair Market Value of HSA as of Date of Death $ l Transfer l to my HSA l to spouse's HSA due to death l to former spouse's HSA due to divorce or legal separation l l l l Disability Pr.

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