Fillable HSA TRANSFER REQUEST INSTRUCTIONS (University of Southern Indiana)

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HSA TRANSFER REQUEST INSTRUCTIONS (University of Southern Indiana)

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HSA TRANSFER REQUEST INSTRUCTIONS
The Health Savings Transfer Request form is used to request the transfer of HSA funds at another financial institution
to The HSA Authority-Old National Bank. These instructions will assist you in completing the HSA Transfer Request form. If
you do not have an open Health Savings Account with The HSA Authority, please open your account through our online
application process first. Approximately one week after you apply, you will receive a Welcome Letter in the mail that will
include your new account number.
Complete the attached form and send it to USI Benefits Department and we will take care of moving the funds for you.
A representative from The HSA Authority will sign the form and then forward it to your
current institution. When the funds
are received, we will mail you a receipt for the deposit.
Please note: It is important that the transfer is processed in this manner to ensure that it is coded as a transfer
and not a new contribution. Your current institution may charge a fee to transfer and/or close the account.
To fill out the HSA Transfer Request Form:
Part 1 Recipient:
Complete with your information and your HSA Authority Health Savings Account number.
(The account number will be on your Welcome Letter or account statement.)
Part 2 Accepting HSA Trustee or Custodian:
This section is pre-filled.
Part 3 Current Account Owner:
Complete with your information and the HSA number for the account you are transferring from.
Part 4 Current Account Trustee or Custodian:
Complete with current trustee or custodian bank’s information.
Part 5 Transfer Instructions:
To move all the funds to your HSA Authority Account:
Under Transfer Options select One-Time Transfer and check Entire Account Balance. If you wish to close
the account, check This Transfer Will Close the Current Account.
Under the Make Payable To section list Old National Bank as Custodian and list your name as Recipient.
The Asset Handling section can be left blank.
Part 6 Signatures:
Please sign on the first line at the bottom. The form does not need to be notarized unless your current
institution requires it. The last line is for a representative from The HSA Authority to sign before forwarding
it to the other institution.
If you have questions, please call our Client Care Center at 888.472.8697 for assistance. They are available Monday
through Friday, 8:00 am – 8:00 pm ET and Saturday 8:00 am – 1:00 PM ET. Additional information is available on our website
at www.theHSAauthority.com.
3302 / 2625H (Rev. 7/2013) (4/2014) ©2014 Ascensus, Inc.
TRANSFER REQUEST
PART 1. RECIPIENT
Individual requesting the transfer
Name (First/MI/Last) __________________________________________
Date of Birth_____________________ Phone ______________________
Email Address________________________________________________
Account Number__________________________________ Suffix ______
RELATIONSHIP TO CURRENT OWNER (Select one)
I am the current account owner.
I am the former spouse of the current account owner.
PART 5. TRANSFER INSTRUCTIONS
TRANSFER OPTIONS (Select one)
One‐Time Transfer
Transfer Amount ____________________________ Transfer Date ________________
Entire Account Balance This Transfer Will Close the Current Account
Recurring Transfer
Transfer Amount ____________________________ Transfer Start Date ________________
Frequency (Select one) Monthly Quarterly Semi‐Annually Annually Other ______________________________________
MAKE PAYABLE TO
_______________________________________________ as Trustee or Custodian of ____________________________________________ HSA
Name of Accepting HSA Trustee or Custodian Name of Recipient
ASSET HANDLING (Investments identified below will be liquidated immediately unless otherwise specified in the Special Instructions section.)
Asset Description Amount to be Transferred Special Instructions
__________________________________________ ______________________ ___________________________________________________________________
__________________________________________ ______________________ ___________________________________________________________________
__________________________________________ ______________________ ___________________________________________________________________
PART 2. ACCEPTING HSA TRUSTEE OR CUSTODIAN
To be completed by the HSA trustee or custodian receiving the assets
Name_______________________________________________________
Address Line 1 ________________________________________________
Address Line 2 PO Box 3606
City/State/ZIP
Phone 1-888-472-8697 Organization Number ____________
Contact Name ________________________________________________
Fax 812-468-1173
PART 3. CURRENT ACCOUNT OWNER
Name (First/MI/Last) __________________________________________
Social Security Number ________________________________________
Account Number__________________________________ Suffix______
CURRENT ACCOUNT TYPE (Select one) HSA Archer MSA
PART 4. CURRENT ACCOUNT TRUSTEE OR CUSTODIAN
Name ______________________________________________________
Address Line 1 _______________________________________________
Address Line 2 _______________________________________________
City/State/ZIP________________________________________________
Phone ______________________________________________________
PART 6. SIGNATURES
I authorize the transfer of these assets and certify that all information provided by me is true and accurate. I understand that I am responsible for
determining that this transfer qualifies under the rules that apply to such transfers and agree to comply with those rules. I assume responsibility for
any consequences that may result from this transfer and I agree that the trustee or custodian is not responsible for any consequences that may arise
from executing this transfer request.
The trustee or custodian signing below agrees to accept the assets being transferred.
X
________________________________________________________________________________________________ _______________________________________
Signature of Recipient Date (mm/dd/yyyy)
X
________________________________________________________________________________________________ _______________________________________
Notary Public/Signature Guarantee (If required by the trustee or custodian) Date (mm/dd/yyyy)
X
________________________________________________________________________________________________ _______________________________________
Authorized Signature of Accepting Trustee or Custodian Date (mm/dd/yyyy)
The HSA Authority
Attn HSA Operations Center
Evansville, IN 47735
n/a
n/a
The Bank of New York Mellon - Benefit Wallet
PO Box 535161
Pittsburgh, PA 15253
Old National Bank - The HSA Authority
n/a
n/a
n/a
n/a
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Completed 15 April 2022

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