PF-16 (3-17) C
Health Savings Account
Transfer to HSA at PayFlex Request Form
Instructions: Complete sections 1, 2 and 3 on this form to transfer an HSA from your current Trustee or Custodian to PayFlex
®
. Some custodians may
require their own form in addition to this form. Please check with your current Trustee, Custodian or agent for any specific requirements.
Mail this form to the address at the bottom of the page.
Section 1: HSA Account Owner Information – PLEASE PRINT
First Name
MI
Last Name
Social Security Number (Required)
Address Line 1 – Street Address (Do not use a PO Box Address)
Address Line 2
City
State
ZIP Code
E-mail Address
Day-Time Telephone Number
Section 2: Type of Transfer – SELECT ONE OF THE FOLLOWING
HSA to HSA Transfer: I currently have HSA funds with another Trustee or Custodian. I want funds in that HSA transferred to my HSA at
PayFlex.
Archer Medical Savings Account (MSA) to HSA Transfer: I currently have MSA funds with another Trustee or Custodian. I want funds in my
MSA transferred to my HSA at PayFlex.
Individual Retirement Account (IRA) to HSA Transfer: I want to transfer funds from my Traditional or Roth IRA to my HSA at PayFlex. I
understand that this must be a direct trustee-to-trustee transfer. I further acknowledge that due to special requirements as established by the
IRS, this transfer may have certain restrictions and tax consequences. I have or will consult my tax advisor with any questions I have.
Section 3: Transfer Instructions – PLEASE PRINT
Current Trustee or Custodian: Please liquidate and transfer per the instructions below. (This is for the account you are transferring to PayFlex.)
Account Number
Name on Account (should match name in section 1)
Custodian Name and Address
Entire Account Balance (Liquidate and transfer my full account balance available)
$ (Liquidate and transfer the amount directed)
Section 4: PayFlex HSA Information – TRANSFER INSTRUCTIONS TO RESIGNING CUSTODIAN/AGENT
Please issue check with a copy of this form to:
PayFlex Systems USA, Inc. as Custodian for (Name of Account Owner)
HSA Operations
PO Box 3317
Carol Stream, IL 60132-3317
1-888-678-8242
Certification and Signature
I certify that the information contained on this form is true and correct. I direct the current custodian or trustee (in Section 3, above) to transfer the HSA,
Archer MSA or IRA funds to PayFlex Systems USA, Inc. I have identified the amount for the transfer above. I understand that I am responsible for any
tax consequences of this action. I indemnify and hold PayFlex, its agents and affiliates, harmless from any resulting liabilities. PayFlex Systems USA,
Inc. shall accept the transferred funds as a transfer to the HSA of the Account Owner and immediately deposit the funds.
HSA Account Owner Signature
Date
Acceptance by PayFlex Systems USA, Inc. – TO BE COMPLETED BY PAYFLEX
PayFlex Systems USA, Inc. (PayFlex) is willing to accept HSA, MSA or IRA funds that the current trustee or custodian holds in accordance with the
above instructions. The Account Owner, by his or her signature above, hereby directs the current trustee or custodian to transfer assets maintained
with the current trustee or custodian, in the amount of the requested distribution set forth above and, after deduction of any necessary fees and
expenses, to PayFlex at the address above (Section 4). Transfers to PayFlex must be in cash equivalents. PayFlex does not accept “in-kind” transfers
of mutual funds or stock.
Accepted by PayFlex (Authorized PayFlex Representative)
Date
Mail this form to: PayFlex Systems USA, Inc., HSA Operations, 13511 Label Lane, Ste 201, Hagerstown MD 21740
