HSA Rollover or Transfer Request HSA Rollover or Transfer Request
To expedite your health savings account (HSA) rollover or transfer, please work directly with the bank where your HSA funds are currently on deposit. Many
banks require that you use their form, so please check with your current bank to be sure they will accept our form, before proceeding with this form.
HSA rollovers or transfers will be applied to the calendar year in which the funds are received. Due to processing time a other financial institutions please allow 4-6 weeks
for the funds to arrive in your Optum Bank HSA. In order to use this form, you must have an Optum Bank HSA. To open an account, visit us at
optumbank.com. Questions? Call the number of the back of your debit card if you have any questions while completing this form.
*Required fields 040 CO HA MCDH HSA
1 Account holder information
Account holder name:* Account holder name:* Account holder name:* Optum account # or SSN:* Optum account # or SSN:* Optum account # or SSN:*
Address:* Address:* Address:*
City, State, Zip:* City, State, Zip:* City, State, Zip:*
Daytime phone #:* Daytime phone #:* Daytime phone #:*
2 Rollover option (Complete this section if depositing a check received from your previous HSA Administrator)
______ By initialing here, I acknowledge that the IRS Code limits the number of rollovers that may be taken, how quickly rollovers must be completed, and how the
bank must report the transaction. I understand that if I need additional information, I will contact my tax advisor. By providing my initials, I am also certifying to the Bank
that Ihave satisfied the rules and conditions applicable to my rollover and that I am making an irrevocable election to treat the transaction as a rollover. I also acknowledge
that I have received a normal distribution from my current HSA Administrator and would like to rollover the funds to my HSA with Optum Bank.
Next step:Sign section 4 of this form and mail the check and completed form to: Optum Bank,P.O. Box 60099 Newark, NJ 07101
3 Transfer option (Complete this section if transferring your HSA currently being administered by another bank)
Remember: Check with your current Administrator to determine their process for transfers and account closures, and be sure to follow that process. They may not
accept our form.
______ By initialing here, I acknowledge that I currently have an HSA with a financial institution other than Optum Bank.and I would like that financial institution to
transfer all assets in my current HSA to my Optum Bank HSA and for my current Administrator to close my account (closing fees with current Administrator may apply).
I understand that I may to need to liquidate HSA assets held in the investment portion of my account, with my current Administrator prior to submitting this form. I
hereby authorize and direct the current Administrator of my HSA to liquidate investment funds on my behalf.
Next step: sign section 4 of this form. Complete section below and send this form to your current HSA Administrator
HSA Administrator name:* HSA Administrator name:* HSA Administrator name:*
Account #:* Account #:* Account #:*
Name on HSA:* Name on HSA:* Name on HSA:*
Administrator phone #:* Administrator phone #:* Administrator phone #:*
Administrator address:* Administrator City, State, Zip:*
Instructions to current administrator:
Transfer all assets in my account to the Optum Bank HSA established in my name. I understand that you will contact me with respect to the disposition of any other
assets in my account that are not transferable. By signing below, I authorize Administrator to deduct any outstanding fees due to the Administrator from the credit
balance in my account. If my account does not contain a credit balance, or if the credit balance in the account is insufficient to satisfy any outstanding fees due to the
Administrator, I authorize you to liquidate the assets in my account to the extent necessary to satisfy that obligation.
Accepting HSA Custodian: Optum Bank, Inc has received a request from the above named individual to accep a transfer of those certain HSA funds held at or by you.
Please be advised that without the validity or timing of whether or not such a transfer is permitted under applicable law, Optum Bank, Inc. is a Utah chartered FDIC-Insured
financial institution that automatically qualifies as a HSA custodian under Internal Revenue Code 408(n) and as such, may accept all HSA and other transfer amounts.
Please remit a check payable to Optum Bank as a custodian/administrator of the above mentioned account for the requested transfer amount, including account owner
name, SSN and form, and mail to: Optum Bank, P.O. Box 60099, Newark, NJ 07101.
Authorized signature of new Trustee of Custodian:
4 Authorization
I have read and understand the rules and conditions referenced herein in this form, including but not limited to, those applicable statutes and rules in connection with
HSA fund transfers and rollovers and I have met the requirements for making a transaction. Due to the important tax consequences when moving funds in an HSA, I
have been advised to seek the advice of a legal or tax professional. All information provided by me herein is true and correct and may be relied on by Optum Bank. I
assume full responsibility for this transaction and acknowledge that Optum Bank is an HSA custodian with no fiduciary responsibilities and as such shall not be liable for
any adverse consequences that may result from any transfer or rollover conducted pursuant hereto.
Authorized signature (physical signature required) Date
© 2021 Optum, Inc. All rights reserved. 30657D-112020
HSAs are individual accounts offered or administered by Optum Bank
®
, Member FDIC, a subsidiary of Optum Financial, Inc.
