Follow the steps to successfully complete the form.

1. Press the ‘Get Form’ button to obtain the form and open it in your preferred document viewer.
2. Begin by filling out your company name in the designated space to identify the account holder.
3. Next, provide the account owner's name clearly, ensuring it matches the records associated with the HSA.
4. Enter the Social Security number accurately, as it is crucial for processing your request.
5. Fill in your complete address, including city, state, and zip code, to facilitate communication and processing.
6. Include your phone number for any necessary follow-up regarding your distribution request.
7. Provide your email address for digital correspondence related to your request.
8. Check the box if your address has changed recently to update the records.
9. Indicate the amount of the requested distribution, ensuring it meets the minimum threshold of $5.00.
10. Specify the date of the distribution request in the provided fields.
11. Read the certification statement thoroughly, then sign and date the form to confirm your understanding and agreement.
12. Once completed, save your changes, download the document if necessary, and prepare to submit your request.
13. Submit this request via mail, fax, or email, as indicated in the contact section of the form.

Complete your documents online now to ensure a smooth distribution process for your HSA.