Return of mistaken HSA contribuon form
Mail or fax completed forms to:
Address: HealthEquity, An: Client Services
15 W Scenic Pointe Dr, Ste 100, Draper, UT 84020
Fax: 520.844.7090
HealthEquity.com
866.346.5800
HSA_Return_of_Mistaken_Contribuon_Form_20180221
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)
Mistaken contribuon informaon
Mistaken contribuon amount: Year of mistaken contribuon:
I cerfy that the above contribuon was the result of a mistake of fact. I understand HealthEquity is not required to accept the
mistaken contribuon and, that I am responsible for any tax consequences that may result from this transacon.
Mistaken contribuon requests may only be accepted for contribuons that were submied by the member on a post-tax basis, and
not for pre-tax contribuons or those submied from another enty. Funds will need to pass through applicable clearing periods
before they are returned. Requests may only be made during the indicated tax year and will result in a decrease in the total amount
contributed for the applicable tax year.
Please note: A $20.00 processing fee may apply and will be deducted from your health savings account (HSA). There must be
sucient funds in your account to cover the processing fee.
Banking informaon
Select only one opon. If no opon is selected, or if there is no veried EFT account on le, a check will be mailed.
c
Opon 1 — Check
c
Opon 2 — Use veried EFT account already on le associated to my HSA. Please provide last 4 of account number .*
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
Authorizaon
By signing below, I swear or arm that the correcon from my HSA in the amount stated above is a correcon of a mistaken
contribuon resulng from a mistake of fact due to reasonable cause. I understand that I am solely responsible for any tax
consequences and penales resulng from improperly reporng this as a mistaken contribuon, instead of a distribuon of excess
contribuon, from 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.
