Complete this informaƟ on online under “My Profi le” in your member portal.
Note: If married, living in a community property state (for example AL, AZ, CA, ID, LA, NV, NM, TX, WA, or WI), and want to designate a primary
benefi ciary other than your spouse, your spouse must agree in wri ng to your designa on and you must submit a physical copy of this form by
mail or fax.
You should consult your legal/tax advisor when comple ng this form, as there may be tax and/or legal consequences to your designa on.
You have the op on to list one or more persons to be the primary and con ngent benefi ciaries for your HSA (including your estate or a trust,
as applicable). If designa ng mul ple primary or con ngent benefi ciaries, indicate the percentage share each should receive, ensuring the
total of each adds up to 100%.
Designa ons are eff ec ve upon receipt by HealthEquity and, unless otherwise specifi ed, cancel all previous HSA benefi ciary designa ons on fi le.
Account Holder InformaƟ on (all fi elds are required)
Last Name First Name M.I.
E-Mail Address Day me Phone
( )
SSN or HealthEquity ID Number (6 or 7 digits)
Primary Benefi ciary(ies)
To ensure mely comple on of your request, please complete all fi elds for each benefi ciary you designate.
Primary Benefi ciary 1 Estate/Trust
Yes
No
Name
SSN or TIN Date of Birth (mm/dd/yyyy)
Address City State ZIP
Rela onship Percent
%
Primary Benefi ciary 2 Estate/Trust
Yes
No
Name
SSN or TIN Date of Birth (mm/dd/yyyy)
Address City State ZIP
Rela onship Percent
%
Primary Benefi ciary 3 Estate/Trust
Yes
No
Name
SSN or TIN Date of Birth (mm/dd/yyyy)
Address City State ZIP
Rela onship Percent
%
Primary Benefi ciary 4 Estate/Trust
Yes
No
Name
SSN or TIN Date of Birth (mm/dd/yyyy)
Address City State ZIP
Rela onship Percent
%
Benefi ciary DesignaƟ on Form
Please mail or fax completed forms to:
Address: HealthEquity, AƩ n: Member Services
15 W Scenic Pointe Dr, Ste 100 Draper, UT 84020
Fax: 801.727.1005
