3302 / 2625H (Rev. 7/2013) ©2013 Ascensus, Inc.
TRANSFER REQUEST
PART 1. RECIPIENT
Individual requesting the transfer
Name (First/MI/Last) __________________________________________
Date of Birth_____________________ Phone ______________________
Email Address________________________________________________
Account Number__________________________________ Suffix ______
RELATIONSHIP TO CURRENT OWNER (Select one)
I am the current account owner.
I am the former spouse of the current account owner.
PART 5. TRANSFER INSTRUCTIONS
TRANSFER OPTIONS (Select one)
One-Time Transfer
Transfer Amount ____________________________ Transfer Date ________________
Entire Account Balance This Transfer Will Close the Current Account
Recurring Transfer
Transfer Amount ____________________________ Transfer Start Date ________________
Frequency (Select one) Monthly Quarterly Semi-Annually Annually Other ______________________________________
MAKE PAYABLE TO
_______________________________________________ as Trustee or Custodian of ____________________________________________ HSA
Name of Accepting HSA Trustee or Custodian Name of Recipient
ASSET HANDLING (Investments identified below will be liquidated immediately unless otherwise specified in the Special Instructions section.)
Asset Description Amount to be Transferred Special Instructions
__________________________________________ ______________________ ___________________________________________________________________
__________________________________________ ______________________ ___________________________________________________________________
__________________________________________ ______________________ ___________________________________________________________________
PART 2. ACCEPTING HSA TRUSTEE OR CUSTODIAN
To be completed by the HSA trustee or custodian receiving the assets
Name_______________________________________________________
Address Line 1 ________________________________________________
Address Line 2 ________________________________________________
City/State/ZIP ________________________________________________
Phone _______________________ Organization Number ____________
Contact Name ________________________________________________
PART 3. CURRENT ACCOUNT OWNER
Name (First/MI/Last) __________________________________________
Social Security Number ________________________________________
Account Number__________________________________ Suffix______
CURRENT ACCOUNT TYPE (Select one) HSA Archer MSA
PART 4. CURRENT ACCOUNT TRUSTEE OR CUSTODIAN
Name ______________________________________________________
Address Line 1 _______________________________________________
Address Line 2 _______________________________________________
City/State/ZIP________________________________________________
Phone ______________________________________________________
PART 6. SIGNATURES
I authorize the transfer of these assets and certify that all information provided by me is true and accurate. I understand that I am responsible for
determining that this transfer qualifies under the rules that apply to such transfers and agree to comply with those rules. I assume responsibility for
any consequences that may result from this transfer and I agree that the trustee or custodian is not responsible for any consequences that may arise
from executing this transfer request.
The trustee or custodian signing below agrees to accept the assets being transferred.
X
________________________________________________________________________________________________ _______________________________________
Signature of Recipient Date (mm/dd/yyyy)
X
________________________________________________________________________________________________ _______________________________________
Notary Public/Signature Guarantee (If required by the trustee or custodian) Date (mm/dd/yyyy)
X
________________________________________________________________________________________________ _______________________________________
Authorized Signature of Accepting Trustee or Custodian Date (mm/dd/yyyy)
