HSA Contribuon Form
Mail or fax completed forms to:
Address: HealthEquity, An: Member Services
15 W Scenic Pointe Dr, Ste 100, Draper, UT 84020
Fax: 801.727.1005
www.healthequity.com 866.346.5800
HSA_Contribution_Form_20200411
Primary Account Holder Informaon
Employer Name
Last Name First Name M.I.
Street Address City State ZIP
E-Mail Address (required) Dayme Phone
( )
SSN or HealthEquity ID Number
Contribuons
Contribuon tax year:
Contributions for the prior ta
x year are accepted until Tax Day of the following year. Funds
will be applied to the tax year of the date on the attached check if no year is indicated.
Banking Informaon
What method would you like to use to make contributions to your HSA?
c Opon 1—Check
Include a check payable to HealthEquity with this form and mail to:
HealthEquity, An: Client Services, 15 W Scenic Pointe Dr, Ste 100, Draper, UT 84020
Include the tax year and your HealthEquity ID number (6 or 7 digits) on the check.
When you provide a check as payment, you authorize HealthEquity to either use the informaon from your check to make a one-me, Back Oce Conversion (BOC), electronic fund
transfer from your account if eligible, or to process the payment as a check transacon. Funds processed via BOC may be withdrawn from your account as soon as the same day your
payment is received.
c Opon 2—One-me electronic funds transfer (EFT)
Fax this form and a copy of a voided check to:
HealthEquity, An: Member Services, 801.727.1005.
Account type: c Checking c Savings Amount of deposit: $
Financial instuon:
City/state:
Roung number: Account number:
Voided check is required if your personal account is not on le.
c Opon 3—Recurring monthly electronic funds transfer (EFT)
Fax this form and a copy of a voided check to HealthEquity, An: Member Services, 801.727.1005. Voided check is required if your personal
account is not on le.
Amount of deposit: $ Day of month funds should be pulled:
Financial instuon: City/state:
Account type: c Checking c Savings Routing number: Account number:
Authorizaon
By signing below, I authorize the deposit of the above stated amount into my HealthEquity health savings account (HSA).
I understand the eligibility requirements of the type of HSA deposit I am making and state that I qualify to make the deposit.
I assume complete responsibility for:
1. Determining that I am eligible for an HSA each year I make a contribuon.
2. Ensuring that all contribuons I make are within the limits set forth by tax laws.
3. The tax consequences of any contribuon (including rollover contribuons) and distribuons.
Name (please print) Signature Date
Please allow three to ve business days aer your form is processed by HealthEquity for your deposit to post to your account.
