Return of mistaken HSA contribuon form
Mail or fax completed forms to:
Address: HealthEquity, An: 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_Contribuon_Form_20180221
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)
Mistaken contribuon informaon
Mistaken contribuon amount: Year of mistaken contribuon:
I cerfy that the above contribuon was the result of a mistake of fact. I understand HealthEquity is not required to accept the
mistaken contribuon and, that I am responsible for any tax consequences that may result from this transacon.
Mistaken contribuon requests may only be accepted for contribuons that were submied by the member on a post-tax basis, and
not for pre-tax contribuons or those submied from another enty. 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
sucient funds in your account to cover the processing fee.
Banking informaon
Select only one opon. If no opon is selected, or if there is no veried EFT account on le, a check will be mailed.
c
Opon 1 — Check
c
Opon 2 — Use veried EFT account already on le associated to my HSA. Please provide last 4 of account number .*
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
Authorizaon
By signing below, I swear or arm that the correcon from my HSA in the amount stated above is a correcon of a mistaken
contribuon 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 resulng from improperly reporng this as a mistaken contribuon, instead of a distribuon of excess
contribuon, from 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.
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