Distribuon of Excess HSA Contribuon Form
Mail or fax completed forms to:
Address: HealthEquity, An: Client Services
15 W Scenic Pointe Dr, Ste 100, Draper, UT 84020
Primary Account Holder Informaon
Employer Name (if applicable)
Last Name First Name M.I.
Street Address City State ZIP
E-Mail Address Dayme Phone
Last 4 of SSN or HealthEquity ID Number
Excess Contribuon Informaon
Excess contribuon amount: Tax year:
This form is required to correct amounts contributed in excess of your contribuon limit for the year. Refer to www.ustreas.gov for the
HSA contribuon limits applicable for each tax year. Please contact HealthEquity Member Services at 866.346.5800 for assistance.
The amount contributed in excess of your contribuon limit is subject to a penalty tax unless the excess and interest earned are
withdrawn prior to the due date, including any extensions, for ling your federal income tax return.
Please note: A $20.00 processing fee may apply and will be reduced from the amount returned. There must be sucient funds in your
account to cover the distribuon of an excess contribuon and any interest earned on excess contribuons.
How would you like the funds distributed? Please check one.
c Opon 1—Change tax year to: (Contribuon will count toward your yearly contribuon maximum.)
c Opon 2—Check (default)
c Opon 3: One-me electronic funds transfer (EFT)
(Form must be accompanied by a copy of a voided or an actual check)
By signing below, I swear or arm that the deposit in the amount stated above is repayment of a mistaken contribuon(s) as dened
by the Internal Revenue Service to my HSA resulng from a mistake of fact due to reasonable cause. I understand that I am solely
responsible for any tax consequences and penales of improper reporng of this deposit as repayment of a mistaken distribuon,
instead of a contribuon, to my HSA.
Name (please print) Signature Date
Note: Incomplete forms will not be processed. In such cases, we will aempt to contact you via email or phone to advise that the
form was missing informaon.
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