Powered by HealthSavings Administrators | Rev. 05/2018
Health Savings Account (HSA)
Excess Contribution Removal Form (Individual)
Instructions: Complete this form to remove excess contributions that you’ve made to your HSA. A check will be sent
to you for the excess contribution amount; however, please note that a $25 excess contribution removal fee will be
deducted from your account.
Mail your completed form to:
HealthSavings Administrators/HSA xChange
P.O. Box 73688
North Chesterfield, VA 23235
Accountholder Information
First Name ________________________________________ Last Name __________________________________________ M.I. ________
Street Address _________________________________________________________________________ Apt / Suite ___________________
City ____________________________________________________________________ State _____________________ ZIP Code __________________________
Social Security Number ____________________________ OR Account Number ______________________________________________
Funds contributed in excess of your contribution limit are subject to penalty and tax unless the excess and any earnings are withdrawn
by you prior to the due date (including extensions) for filing your federal income tax return. You should consult a qualified tax professional
for advice on your excess contribution removal.
NOTE: The Internal Revenue Service requires FPS Trust to report withdrawals that are considered refunds of excess contributions. In
order for the withdrawal to be accurately reported, you may not withdraw the excess directly. Instead, you must request an excess
contributions refund by faxing or mailing this signed and completed form to HealthSavings Administrators, using the address or fax
number listed above.
A $25 excess contribution removal fee will be deducted from your account.
Please send me a check for the amount indicated below, plus any applicable earnings.
Excess Contribution Amount $________________
Tax Year ___________
Health savings accounts (HSA) contribution maximums are determined by the IRS. For more information, please visit the U.S.
Department of the Treasury website, http://1.usa.gov/1C87Mv2.
By signing below, I hereby authorize a refund of the excess contribution specified above, plus any earnings on the requested amount.
______________________________________________________________ ___________________________
Accountholder Signature Date (mm|dd|yyyy)
Excess Contribution Removal
Signature
FOR OFFICE USE ONLY
Case Number _______________________________________________________________
