Fillable CONTRIBUTION AND INVESTMENT SELECTION (Georgia's Own Credit Union)

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CONTRIBUTION AND INVESTMENT SELECTION (Georgia's Own Credit Union)

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Page 1 of 2
3107 / 2614H (Rev. 10/2015) ©2015 Ascensus, Inc.
CONTRIBUTION AND INVESTMENT SELECTION
PART 1. HSA OWNER
Name (First/MI/Last) _________________________________________
Social Security Number _______________________________________
Date of Birth ____________________ Phone _____________________
Email Address _______________________________________________
Account Number__________________________________ Sux _____
PART 2. HSA TRUSTEE OR CUSTODIAN
To be completed by the HSA trustee or custodian
Name _____________________________________________________
Address Line 1 ______________________________________________
Address Line 2 ______________________________________________
City/State/ZIP _______________________________________________
Phone________________________ Organizaon Number ___________
PART 3. CONTRIBUTION INFORMATION
Contribuon Amount ____________________________ Contribuon Date ________________
CONTRIBUTION TYPE (Select one)
1. Regular (Includes catch-up contribuons as well as qualied HSA funding distribuons from an IRA)
Contribuon for Tax Year _________ (Qualied HSA funding distribuons from an IRA must be made for the current tax year)
2. Rollover (Distribuon from an HSA or Archer MSA that is being deposited into this HSA)
By selecng this transacon, I irrevocably designate this contribuon as a rollover.
3.Transfer (Direct movement of assets from an HSA or Archer MSA into this HSA)
PART 4. INVESTMENT AND DEPOSIT INFORMATION
INVESTMENT INFORMATION (Complete this secon as applicable.)
Quanty Status Investment Term Interest
InvestmentDescripon orAmount (new or exisng) Number orMaturityDate Rate
_______________________________________________ ___________________ ___________ _______________________ _____________ ___________
_______________________________________________ ___________________ ___________ _______________________ _____________ ___________
_______________________________________________ ___________________ ___________ _______________________ _____________ ___________
DEPOSITMETHOD
CashorCheck (If the contribuon type is transfer, the check must be from a nancial organizaon made payable to the trustee for this HSA.)
InternalAccount
Account Number _____________________________________________ Type (e.g., checking, savings, HSA) _______________________________
ExternalAccount(e.g., EFT, ACH, wire) (Addional documentaon may be required and fees may apply.)
Name of Organizaon Sending the Assets ___________________________________________ Roung Number (Oponal) ___________________
Account Number _____________________________________________ Type (e.g., checking, savings, HSA) _______________________________
Deposit Taken by ____________________________________
PART 5. SIGNATURE
I cerfy that all of the informaon provided by me is accurate and may be relied upon by the trustee or custodian. I cerfy that the contribuon
described above is eligible to be contributed to the HSA and I authorize the deposit/investment in the manner described above.
X_________________________________________________________________________________________________ ______________________________________
Signature of HSA Owner Date (mm/dd/yyyy)
Page 2 of 2
3107 / 2614H (Rev. 10/2015) ©2015 Ascensus, Inc.
RULES AND CONDITIONS APPLICABLE TO HSA CONTRIBUTIONS
HSA contribuon rules are oen complex. The general rules are listed below. If you have any quesons regarding a contribuon, please consult with
a competent tax professional or refer to IRS Publicaon 969, Health Savings Accounts and Other Tax-Favored Health Plans, for more informaon.
This publicaon is available on the IRS website at www.irs.gov or by calling 1-800-TAX-FORM.
REGULAR
The total amount you may contribute to an HSA for any tax year cannot exceed the published annual limit. A qualied HSA funding distribuon is a
one-me direct movement of assets from a Tradional IRA or Roth IRA, and is treated as a regular HSA contribuon.
• You may make a contribuon for the prior year up unl your tax ling deadline for that year, not including extensions. Designang a contribuon
for the prior year is irrevocable.
• If you are age 55 or older by the end of the year, you may be eligible to make an addional catch-up contribuon to an HSA for that tax year.
ROLLOVER
A rollover is a distribuon and a subsequent tax-free movement of assets from any of your other HSAs or Archer medical savings accounts (MSAs) to
your HSA.
• You are permied to make only one rollover contribuon to any of your HSAs in a 12-month period.
• A rollover generally must be completed within 60 days from the date you receive the assets.
TRANSFER
A transfer is a direct movement of assets to your HSA from any of your other HSAs or Archer MSAs. You may perform an unlimited number of
transfers.
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CONTRIBUTION AND INVESTMENT SELECTION (Georgia's Own Credit Union)

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Completed 23 December 2020

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