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Questions? Go to or call 800-544-3716.
One-Time Withdrawal —
Fidelity Health Savings Account (HSA)
Use this form to request a one-time withdrawal from your Fidelity HSA
. Do NOT use this form to request a return of excess contri-
bution, transfer of assets, or distribution due to change in ownership. Go to to find the appropriate form. Type on
screen or fill in using CAPITAL letters and black ink. If you need more room for information, make a copy of the relevant page.
Helpful to Know
It is your responsibility to ensure that your HSA with-
drawals comply with IRS rules. All transactions made
using this form are reported to the IRS as an HSA
distribution. You are responsible for maintaining suffi-
cient records in determining withdrawals used to pay
for qualified medical expenses. You may want to consult
a tax advisor regarding the tax implications associated
with each withdrawal.
Nonresident aliens must provide IRS Form W-8BEN.
The nonresident alien tax-withholding rate of 30% will
generally apply to all distributions.
HSA withdrawal requests are paid from the cash avail-
able in the core position of your account. You must
ensure that there is sufficient cash available in the core
position for your withdrawal. If there is not sufficient cash
available and you need to sell a security, visit us
at, allowing at least three (3) business days
for trade settlement before your withdrawal.
1. Account Owner
Name Fidelity HSA Account Number
Social Security or Taxpayer ID Number
2. Withdrawal Amount
Distribute all assets and close account. Contact your employer to stop any payroll contributions to this account, if appli-
cable. Allow sufficient time for processing prior to submitting this request.
ONLY the following amount from your FDIC-insured sweep account:
3. Withdrawal Method
You must obtain a Medallion signature guarantee in Section 4 if requesting a bank wire, if sending the withdrawal to a payee other than the
HSA owner or to an alternate address, if the address on the account has been changed within the past 10 days, or for any transaction over
Check mailed to the address of record.
Default if no choice indicated or if we are unable to process your choice.
Distribute to a Fidelity nonretirement account: Requires Medallion signature guarantee if going to an account of which you
are not an owner.
Fidelity Nonretirement or HSA Account Number Fidelity Fund Name or Symbol Mutual fund accounts ONLY
Electronic funds transfer (EFT) to bank or credit union account using EFT instructions already in place on the
account (cash only). This form cannot be used to set up EFT. To add EFT to an account, go to or
complete the Electronic Funds Transfer (EFT) Authorization form. If EFT has not been established prior to the receipt
of this request, a check will be mailed to the address of record.
Bank Account Number
Check one.
Check one and
provide all required
Provide bank informa-
tion ONLY if there are
multiple EFT instruc-
tions on the account
identified in Section 1.
1.852488.108 019250601
Withdrawal Method continues on next page.
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Bank wire to a bank or credit union account in your name or someone else’s (cash only): Ask the bank for its wire
routing number. The bank may charge a fee for wire transfers.
Wire Recipient
Bank Routing /ABA Number Bank Name
Account Number Account Owner Name(s) Required
Address of Wire Recipient
City State/Province ZIP/Postal Code Country
For Further Credit
Additional Details (if applicable) Instructions to be included with the wire transfer.
Correspondent (Intermediary)
Correspondent Bank Routing/ABA Number Correspondent Bank Name
Account is OUTSIDE the United States:
SWIFT Code Name of Country
Check mailed to an alternate address: Requires a Medallion signature guarantee.
For Benefit of/Attention
City State ZIP Code
All bank wire
requests MUST
have a Medallion
signature guarantee.
A notary seal/stamp is
NOT a Medallion
signature guarantee.
FULL address is
required for
international wires.
If the bank uses a corre-
spondent bank, provide
the information here.
Correspondent bank
information may not be
required for all wires.
Indicate if the recipient
bank is outside the
United States.
3. Withdrawal Method, continued
Form continues on next page.
1.852488.108 Page 3 of 3 019250603
On this form, “Fidelity” means Fidelity Brokerage Services LLC and its affiliates. Brokerage services are
provided by Fidelity Brokerage Services LLC, Member NYSE, SIPC. 467758.10.0 (08/19)
Did you sign the form? Send the ENTIRE form
to Fidelity Investments.
Questions? Go to or
call 800-544-3716.
Regular mail
Attn: Retirement Distributions
Fidelity Investments
PO Box 770001
Cincinnati, OH 45277-0035
Overnight mail
Attn: Retirement Distributions
Fidelity Investments
100 Crosby Parkway KC1B
Covington, KY 41015
4. Signature and Date Account owner must sign and date.
By signing below, you:
Authorize and request the custodian of the
Fidelity HSA
, Fidelity Personal Trust Company
and its agents, affiliates, employees, or
successor custodians (“Fidelity”), to execute
the instructions you have provided above.
Understand that withdrawals from your HSA,
including earnings, will be tax free (for fed-
eral tax purposes) if used to pay for qualified
medical expenses for yourself, your spouse,
and your dependents. Withdrawals used
to pay for expenses other than qualified
medical expenses are considered taxable
income and will be subject to an additional
20% penalty. The 20% penalty will not apply
to withdrawals made after your death, you
become disabled, or once you reach age 65.
Understand that you are responsible for
determining whether or not a particular
medical expense is a qualified expense
and that you must keep all receipts and
records for tax purposes. Qualified medi-
cal expenses are defined by the Internal
Revenue Code and generally cover most
medical care and services, dental and vision
care, prescription drugs (including pre-
scribed over-the-counter drugs) and insulin
that are not covered by insurance or other-
wise. For more details on what constitutes
a qualified medical expense, please refer to
IRS publications 969 and 502 or contact a
tax professional.
Indemnify Fidelity from any liability
in the event that you fail to meet any
IRS requirement.
Confirm, if you are not a U.S. person, that
you have attached, or have on file with
Fidelity, IRS Form W-8BEN that includes your
U.S. or foreign tax identification number.
Customers requesting EFTs
Authorize and request Fidelity to make EFT
distributions by initiating debit entries from the
Fidelity HSA account indicated on this form.
Authorize and request the bank named in
Section 3 to accept debit entries initiated
by Fidelity in such account and to credit
the bank account in accordance with these
entries without responsibility for the appro-
priateness or for the existence of any further
A Medallion signature guarantee is required:
• to send a check to an alternate address or payee.
• to request a bank wire.
• if the address on the account has been changed within the past 10 days.
• if the withdrawal is going to a Fidelity account with no common owner.
• if the transaction is greater than $100,000.
If the form is completed at a Fidelity Investor Center, the Medallion signature guarantee is not required. You can get a Medallion signature
guarantee from most banks, credit unions, and other financial institutions. A notary seal/stamp is NOT a Medallion signature guarantee.
Questions? Go to or call 800-343-3548.
Let’s Talk about Protecting Your Money
A wire transfer is an easy, convenient way to send money to people you know. If you provide your information or send money to a scammer,
though, there is often little we can do to help get your money back. Here are some examples of common scams, things to ask yourself
before sending any funds, and what to do next if faced with one of these scams. Remember, in EVERY scenario, the first step is to STOP
communicating with the person immediately!
Romance Scam
What is it? A romance scam is a fraudulent scheme in which a fraudster pretends romantic interest in a target, establishes a relationship,
and then attempts to get money or personal sensitive information from the target under false pretenses.
What to do next if you suspect you’re a victim:
• Talk to someone you trust about your new relationship.
• Do a reverse image search of the person’s picture to see if it’s associated with another name or if the details don’t match.
Grandparent Scam
What is it? A scammer calls or emails you, posing as either a relative in distress or someone claiming to represent the relative (such as a
lawyer or law enforcement agent). The caller explains that the “relative” is in trouble and needs them to wire funds “immediately” for bail
money, lawyer’s fees, hospital bills, or another fictitious expense.
What to do next if you suspect you’re a victim:
• Call the relative (or their parent) directly, at their known phone number.
• If told you have to act quickly, resist that urge.
Verify, verify, verify!
Sweepstakes/Inheritance Scam
What is it? You receive a notice stating that you’ve won a “big prize” or have received an unexpected inheritance. You’re told that in order
to claim the “prize” or “inheritance,” you need to send funds to cover “processing fees” or “taxes.” Once the money is sent, you never see
your prize or inheritance.
What to do next if you suspect you’re a victim:
Independently verify the information by consulting reputable resources. Do not rely on resources the scammer gives you, since they are
probably involved in the scam as well.
Remember, you cannot win a sweepstakes you never entered!
Investment Scam
What is it? An investment scam involves the illegal or purported sale of a financial instrument. The typical investment scam is characterized
by offers of low or no-risk investments, guaranteed returns, etc.
What to do next if you suspect you’re a victim:
Don’t trust a person or company just because they have a website; a convincing website can be set up quickly.
• Be cautious when responding to special investment offers, especially through unsolicited email.
Check with other resources regarding this person or company, and inquire about all the terms and conditions.
Watch for red flags Here are some examples of red flags that should make you think twice before sending money.
• A person or company solicits business from you rather than your finding them on your own.
• The requestor asks you to send the wire to a name different from their own.
• After just a few contacts, they profess strong feelings for you and ask to chat with you.
• They threaten legal action if the funds are not sent “right away.”
• The wiring instructions seem unusual, they change, or you’re asked to go to a different financial institution.
• You are coached on how to respond to questions your financial institution might ask you regarding the transaction.
• If you met on a dating site, they will try and move you away from the site and communicate via chat or email instead.
• Messages may be full of typing errors, poorly written, or vague, and may escalate quickly if you show resistance.
• The messages or calls become more desperate and/or persistent, and if you do send money, they ask you to send more.
Remember, if it seems too good to be true, it probably is!
Your security is our top priority. We’re here to help. If you have any concerns or want to know more about how to help protect yourself, talk to a
Fidelity representative or visit Fidelity’s Security Center online at 928234.1.0 (05/20)
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