Get Hsa Distribution Request Form

Filling out the HSA Distribution Request Form online is a straightforward process. This guide provides clear instructions for each section of the form, helping users navigate through the required fields and ensure accurate submissions.

Follow the steps to complete the HSA Distribution Request Form effectively.

1. Click ‘Get Form’ button to obtain the HSA Distribution Request Form and open it in the editor.
2. Begin by entering your account holder information. Fill in your account holder name (first, middle initial, last), social security number, employer name (avoid abbreviations), and employee ID. Ensure that your day telephone number and complete mailing address, including city, state, and zip code, are accurate.
3. Proceed to the distribution information section. Here, specify the requested amount and select the reason for distribution from the options provided: normal, disability, prohibited transaction, excess contribution removal, transfer, or death. If applicable, provide the name and address of the beneficiary.
4. If the distribution is due to death, indicate whether it is taken in the year of death. Check the box for 'Close HSA' only if you wish to close your account, understanding that a $25.00 fee will be deducted from your balance.
5. In the authorized signatures section, confirm that you are the appropriate party to receive funds. You must sign and date the form, affirming that all information provided is true and accurate.
6. Once all sections are completed, you can save changes, download, print, or share the form as needed.

Take action now and complete your HSA Distribution Request Form online.