www.healthequity.com 866.346.5800
Mistaken_HSA_Distribuon_Form_20151112
Primary Account Holder Informaon
Employer Name (if applicable)
Last Name First Name M.I.
Street Address City State ZIP
Email Address (required) Dayme Phone
( )
Last 4 of SSN or HealthEquity ID Number (6 or 7 digits)
Distribuon Informaon
Amount of mistaken distribuon: $ Year of mistaken distribuon:
I cerfy that the above distribuon was the result of a mistake of fact and I authorize HealthEquity to redeposit the distribuon as
a mistaken distribuon.
I understand HealthEquity is not required to accept the mistaken distribuon and, that I am responsible for any tax consequences
that may result from the distribuon.
Banking Informaon (If no opon is selected, form is void)
c
Opon 1 Check
Include a check payable to HealthEquity with this form and mail to:
HealthEquity, An: 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 informaon from your check to make a one-me, Back Oce Conversion (BOC), electronic fund
transfer from your account if eligible, or to process the payment as a check transacon. Funds processed via BOC may be withdrawn from your account as soon as the same day your
payment is received.
c
Opon 2 Use veried EFT account already on le associated to my HSA. Please provide last 4 of account number .*
Note: Account must be veried for contribuons in order for HealthEquity to pull the funds via EFT.
c
Opon 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 arm that this deposit, in the amount stated above, to my health savings account (HSA) is repayment of
a mistaken distribuon or distribuons as dened by the Internal Revenue Service (resulng from a mistake of fact due to reasonable
cause). I understand that I am solely responsible for any tax consequences and penales of improper reporng of this deposit as
repayment of a mistaken distribuon, instead of a contribuon, to my HSA.
Name (please print) Signature Date
Note: Incomplete forms will not be processed. In such cases, we will aempt to contact you via email or phone to advise that the
form was missing informaon.
Mistaken HSA Distribuon Form
Email, mail or fax completed forms to:
Email: memberservices@healthequity.com
Address: HealthEquity, An: Member Services
15 W Scenic Pointe Dr, Ste 100, Draper, UT 84020
Fax: 520.844.7090
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