www.healthequity.com 866.346.5800
Mistaken_HSA_Distribuon_Form_20151112
Primary Account Holder Informaon
Employer Name (if applicable)
Last Name First Name M.I.
Street Address City State ZIP
Email Address (required) Dayme Phone
( )
Last 4 of SSN or HealthEquity ID Number (6 or 7 digits)
Distribuon Informaon
Amount of mistaken distribuon: $ Year of mistaken distribuon:
I cerfy that the above distribuon was the result of a mistake of fact and I authorize HealthEquity to redeposit the distribuon as
a mistaken distribuon.
I understand HealthEquity is not required to accept the mistaken distribuon and, that I am responsible for any tax consequences
that may result from the distribuon.
Banking Informaon (If no opon is selected, form is void)
c
Opon 1 — Check
Include a check payable to HealthEquity with this form and mail to:
HealthEquity, An: Client Services, 15 W Scenic Pointe Dr, Ste 100, Draper, UT 84020
When you provide a check as payment, you authorize HealthEquity to either use the informaon from your check to make a one-me, Back Oce Conversion (BOC), electronic fund
transfer from your account if eligible, or to process the payment as a check transacon. Funds processed via BOC may be withdrawn from your account as soon as the same day your
payment is received.
c
Opon 2 — Use veried EFT account already on le associated to my HSA. Please provide last 4 of account number .*
Note: Account must be veried for contribuons in order for HealthEquity to pull the funds via EFT.
c
Opon 3 — One-me electronic funds transfer (EFT). (Form must be accompanied by a copy of a voided or an actual check)
*Required elds
Signature
By signing below, I swear or arm that this deposit, in the amount stated above, to my health savings account (HSA) is repayment of
a mistaken distribuon or distribuons as dened by the Internal Revenue Service (resulng from a mistake of fact due to reasonable
cause). I understand that I am solely responsible for any tax consequences and penales of improper reporng of this deposit as
repayment of a mistaken distribuon, instead of a contribuon, to my HSA.
Name (please print) Signature Date
Note: Incomplete forms will not be processed. In such cases, we will aempt to contact you via email or phone to advise that the
form was missing informaon.
Mistaken HSA Distribuon Form
Email, mail or fax completed forms to:
Email: memberservices@healthequity.com
Address: HealthEquity, An: Member Services
15 W Scenic Pointe Dr, Ste 100, Draper, UT 84020
Fax: 520.844.7090
