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R08.15 Health Savings Account (HSA) or Medical Savings Account (MSA) Withdrawal Form 9 UMB Health Savings Account Number (10digit number found on your HSA statement) 8 As owner of the Health Savings.

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In order for the withdrawal to be accurately reported, you may not withdraw the excess directly. Instead, you must request an excess contributions refund by faxing or mailing this signed and completed form to UMB, using the address or fax number listed below.

You may withdraw any portion or all of the funds from one HSA or Archer MSA and roll them into an HSA with another custodian or trustee. However, you are required to roll the funds into a new HSA within 60 calendar days of your receipt of the funds.

You can submit a withdrawal request form to receive funds (cash) from your HSA. If the cash is used to pay for ineligible purchases, it must be reported when you're filing your taxes. Once it's reported, it's subject to an income tax and treated as though it had never been in your tax-free HSA.

The HSA debit card can be used to pay for qualified medical expenses for the accountholder and their dependents. When using their debit card at a merchant location (other than an ATM), they will enter “credit” into the merchant's keypad at checkout, or let the cashier know that the purchase is a “credit” transaction.

You will receive a signature-based debit card with ATM access for your HSA. There is no charge to use the card at merchants and health care providers, but fees apply if it is used at an ATM. UMB charges a monthly service fee for HSA custodial services.

Return completed form to: UMB Bank, n.a. Mailstop 1020502 — HCS Department. P.O. Box 419226. Kansas City, MO 64141-6226. Or Fax to: 816.843.2247. Or e-mail scanned document to: HSA.Administration@umb.com.

Online Transfer – On HSA Bank's Member Website, you can transfer funds from your HSA to an external bank account, such as a personal checking or savings account. There is a daily transfer limit of $2,500 to safeguard against fraudulent activity.

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© Copyright 1997-2025
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Form Packages
Adoption
Bankruptcy
Contractors
Divorce
Home Sales
Employment
Identity Theft
Incorporation
Landlord Tenant
Living Trust
Name Change
Personal Planning
Small Business
Wills & Estates
Packages A-Z
Form Categories
Affidavits
Bankruptcy
Bill of Sale
Corporate - LLC
Divorce
Employment
Identity Theft
Internet Technology
Landlord Tenant
Living Wills
Name Change
Power of Attorney
Real Estate
Small Estates
Wills
All Forms
Forms A-Z
Form Library
Customer Service
Terms of Service
DMCA Policy
About Us
Blog
Affiliates
Contact Us
Privacy Notice
Delete My Account
Site Map
All Forms
Search all Forms
Industries
Forms in Spanish
Localized Forms
Legal Guides
Real Estate Handbook
All Guides
Prepared for You
Notarize
Incorporation services
Our Customers
For Consumers
For Small Business
For Attorneys
Our Sites
US Legal Forms
USLegal
FormsPass
pdfFiller
signNow
airSlate workflows
DocHub
Instapage
Social Media
Call us now toll free:
1-877-389-0141
As seen in:
  • USA Today logo picture
  • CBC News logo picture
  • LA Times logo picture
  • The Washington Post logo picture
  • AP logo picture
  • Forbes logo picture
© Copyright 1997-2025
airSlate Legal Forms, Inc.
3720 Flowood Dr, Flowood, Mississippi 39232