For Calendar year 2017, an HSA may be established by you on or before April 16, 2018. You may pay or reimburse on a tax-free basis
a qualified medical expense if that expense was incurred on or after the date the HSA has been established
PURPOSE. The Health Savings Account (HSA) Distribution Form is designed to assist you in selecting a HSA distribution reason and
method.
FORM – HSA Distribution, Pg. 2 of 2, Rev. 12/17
FOR ADDITIONAL GUIDANCE. It is in your best interest to seek the guidance of a tax or legal professional before completing this
document. Your first reference should be the HSA agreement and disclosure statement you received upon establishing your HSA or
amendments provided by your custodian/trustee. For more information, refer to Internal Revenue Code (IRC) Section 223 and all aditional
Internal Revenue Service (IRS) guidance, IRS publications that include information about HSAs, IRS Publication 505-Tax Withholding and
Estimated Tax, Instructions to your federal income tax return, your local IRS office, or the IRS's web site at www.irs.gov.
TERMS. A general understanding of the following terms may be helpful in completing your transactions.
Qualified medical expenses are expenses paid by you, your spouse, or your dependents for medical care as defined in IRC section
213(d) . The qualified medical expenses must be incurred only after the HSA has been established.
NORMAL. Normal distribution include distributions for qualified medical expenses and all other distributions except the following
disability, death, transfer, prohibited transaction, revocation, and correction of excess contribution.
Your beneficiary(ies) should be prepared to provide a death certificate and identification to the custodian/trustee. A representative of
your estate should be prepared to also provide copies of appropriate documentation, such as letter of appointment, for your state of
residence.
DEATH. Upon your death, your HSA becomes the HSA of your spouse as of the date of your death, if he/she is the beneficiary. We
may require you spouse to transfer the assets to an HSA of his/her own. Your spouse is subject to income tax only to the extent
distributions from the inherited HSA are not used for qualified medical expenses.
If your beneficiary is not your spouse, the HSA ceases to be an HSA as of the date of your death. If your beneficiary is your estate, the
fair market value of your HSA as of the date of your death is taxable on your final return. For other beneficiaries, the fair market value
of your HSA is taxable to them in the tax year that includes such date. For such a person (except your estate), this amount is reduced
by any payements for the HSA made for your qualified medical expenses, if paid within one year after your death.
EXCESS CONTRIBUTION. An excess contribution occurs when the contribution amount exceeds allowable limits or when an
individual or nonindividual makes an ineligible contribution. Removing an excess contribution, plus attributable earnings, by your tax-
filing due date, including extensions, avoids a 6 percent excise tax.
FAIR MARKET VALUE. The most recent regularly determined value of the HSA assets determined as of a date that coincides with or
precedes the date of your death.
ADDITIONAL DOCUMENTS. Applicable law or policies of the HSA custodian/trustee may require additional documentation. A separate
distribution form must be completed for each distribution reason.
RECIPIENT INFORMATION. The Recipient Information section must be completed for a distribution made to satisfy an IRS levy, a death
distribution, a transfer to another HSA, a transfer to a former spouse's HSA due to divorce or legal separation, or a transfer to a spouse's
HSA due to death. Provide complete information regarding the individual or entity receiving the assets.
TRANSFER. A transfer is the nonreportable movement of assets between HSAs.
DISABILITY. A distribution for disability can avoid the additional 10 percent tax if you are younger than age 65 and are disabled. The
custodian/trustee may request a copy of a physician's certificate that states you meet the definition of disability under IRC Section
72(m)(7).
