HSATRANS-12/17 Member FDIC Page 1 of 1
Account Owner Name:
City: State: Zip Code:
Phone: SSN: DOB:
I hereby request an HSA to HSA, Archer MSA to HSA, IRA to HSA account transfer
to Cattle Bank & Trust.
Current Trustee Name: Trustee Address:
Trustee City: Trustee State: Trustee Zip:
Trustee Phone: Trustee Account Number:
Please send cash proceeds for my entire HSA, Archer MSA, IRA account balance OR
a portion of my HSA, Archer MSA, IRA account balance of $__________________.
I authorize you to immediately liquidate all investments as necessary. Proceeds should be made
payable to Cattle Bank & Trust as custodian for the HSA of ____________________________,
Account Number __________________ and sent to:
Cattle Bank & Trust
P.O. Box 467
Seward, NE 68434-0467
I certify that the information on this transfer request is true and correct as of this date. I direct the
transferring custodian to transfer my HSA/Archer MSA/IRA assets as directed in this transfer request. I
understand that I am solely responsible for seeking appropriate tax and/or legal advice regarding the
consequences of this request. I understand that both the transferring and receiving trustees cannot offer tax
and legal advice and I agree to hold them harmless against any liabilities arising from this transfer request.
I assume full responsibility for this transfer request and understand that fees or penalties may be imposed
by the transferring or receiving trustees per their policies.
Account Owner Signature Date
Cattle Bank & Trust hereby agrees to accept these funds as HSA custodian.
Custodian Authorized Signature Date
Cattle Bank & Trust
Health Savings Account
Transfer Request Form
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