Authorizaon for account closure
To authorize HealthEquity to close your health savings account (HSA), complete this form. A closure fee of up to $25.00 may apply. Please contact
HealthEquity at 866.346.5800 to determine the exact fee. In order to allow for all transacons to sele, your account will be frozen for a period
of at least ve (5) business days prior to its being closed. Please note that if you choose to receive a check for any remaining funds mailed to you,
allow 7 to 10 business days aer the end of the freeze period to receive your check.
The funds you receive from an HSA must be deposited into another HSA or used for qualied medical expenses within 60 days aer you receive
them to avoid taxes and penales. There are generally no excepons to the 60-day rule and the IRS will not grant extensions. Receipt generally
means the day you actually have the funds in hand.
Note: You must liquidate all investments before your HSA can be closed. HealthEquity does not automacally liquidate investments on your behalf.
To do this, you must log in to your online account and select “Sell All” for each of the funds that you own.
Primary account holder informaon
Last name First name M.I.
Street address City State ZIP
Email address (required) Dayme phone
( )
Last 4 of SSN or HealthEquity ID number
Reason for account closure
Note: If this closure is due to the death of the account holder, please use the HSA Instrucons Upon Death form.
Closure method
Please close my HealthEquity HSA. I understand that the remaining balance, less applicable closure fees, will be mailed to the address on le.
Signature required below.
c
Send via check (funds will be mailed to address on le)
c
Send via EFT to bank account on le (EFT not available for closure due to death)
Financial instuon:
Roung number: Account number:
Form must be accompanied by a copy of a voided or an actual check.
Transfer to another HSA custodian
Please close my HealthEquity HSA. I am requesng that the remaining balance, less applicable closure fees, be sent via check to the HSA custodian
below with whom I have an account. EFT transfer is not supported on a transfer to another custodian. Signature required below.
Instuon name Account number
Street address City State ZIP
Authorizaon to close account (If form is le blank, funds will be mailed via check to address on le)
Name (please print) Signature Date
Please allow up to three weeks for the distribuon or transfer to be mailed.
HSA_Closure_request_form_20200203
www.HealthEquity.com
866.346.5800
HSA Closure request form
Mail or fax completed forms to:
Address: HealthEquity, An: Client Services
15 W Scenic Pointe Dr, Ste 100, Draper, UT 84020
Fax: 801.846.2929
