Distribuon of Excess HSA Contribuon Form
Mail or fax completed forms to:
Address: HealthEquity, An: Client Services
15 W Scenic Pointe Dr, Ste 100, Draper, UT 84020
Fax: 520.844.7090
Primary Account Holder Informaon
Employer Name (if applicable)
Last Name First Name M.I.
Street Address City State ZIP
E-Mail Address Dayme Phone
( )
Last 4 of SSN or HealthEquity ID Number
Excess Contribuon Informaon
Excess contribuon amount: Tax year:
This form is required to correct amounts contributed in excess of your contribuon limit for the year. Refer to www.ustreas.gov for the
HSA contribuon limits applicable for each tax year. Please contact HealthEquity Member Services at 866.346.5800 for assistance.
The amount contributed in excess of your contribuon 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withdrawn prior to the due date, including any extensions, for ling your federal income tax return.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 sucient funds in your
account to cover the distribuon of an excess contribuon and any interest earned on excess contribuons.
Banking Informaon
How would you like the funds distributed? Please check one.
c Opon 1—Change tax year to: (Contribuon will count toward your yearly contribuon maximum.)
c Opon 2—Check (default)
c Opon 3: One-me electronic funds transfer (EFT)
Financial instuon:
Routing number:
Account number:
(Form must be accompanied by a copy of a voided or an actual check)
By signing below, I swear or arm that the deposit in the amount stated above is repayment of a mistaken contribuon(s) as dened
by the Internal Revenue Service to my HSA resulng from a mistake of fact due to reasonable cause. I understand that I am solely
responsible for any tax consequences and penales of improper reporng of this deposit as repayment of a mistaken distribuon,
instead of a contribuon, to my HSA.
Name (please print) Signature Date
Note: Incomplete forms will not be processed. In such cases, we will aempt to contact you via email or phone to advise that the
form was missing informaon.
click to sign
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