*Required Fields
Step 1: Customer Information
*Employer Name (If sponsored by an employer plan) *Customer Name (First, MI, Last)
*Bank of America HSA Account Number
/ / – – ( ) -
*Birth Date (MM/DD/YYYY) *Social Security Number *Day Telephone
*Permanent Address *Email Address
*City *State *Zip Code
Step 2: Transferring Trustee/Custodian
*Transferring Trustee/Custodian Name *Contact Name
*City *State *Zip Code
*Account Number
Instructions: Use this form to request all or a portion of assets be transferred from another
HSA, Archer MSA or IRA into your Bank of America HSA. Transfers may take 3 to 6 weeks
depending on your previous trustee/custodians processing time. Please ensure that your
Bank of America account is set up prior to requesting the transfer, as you will need your
account number to complete the transfer.
You may only transfer funds if you are the customer of the transferring HSA, Archer MSA or
IRA, the surviving spouse of a deceased customer, or the former spouse of the customer who is
receiving an interest in the HSA, Archer MSA or IRA pursuant to a divorce or separation agreement.
Complete this form by entering the required customer information below.
Mail the original completed form to your current trustee for processing.
Health Savings Account
Transfer Request Form
We’re here to help
you 24 hours a day,
7 days a week.
Customer Care Center:
800.305.5109 TDD
Online Chat:
Health Savings Account
Transfer Request Form (cont’d)
Step 3: Instructions to the Transferring Trustee/Custodian
3a) Originating Account Type:
3b) Total Amount to Transfer:
Entire Account Balance
Keep my HSA Open
Close my HSA
Specific Dollar Amount: $
3c) Transfer by check, payable to “BOA as HSA Administrator of” (Owners Name)
3d) Mail check attached to this form to: Bank of America c/o Health Account Services, PO Box 2203, Fargo, ND 58108
Step 4: Acknowledgement & Signature:
I have read and understand the trustee-to-trustee transfer rules and conditions and I have met the requirements for making
a transfer. Due to the important potential tax consequences of transferring funds into an HSA, I understand that I should consult with
a tax professional concerning these transactions. All information provided by me is true and correct and may be relied on by Bank of
America Health Benefit Solutions. I assume full responsibility for this funds transfer transaction and will not hold Bank of America
Health Benefit Solutions liable for any adverse consequences that may result. I hereby irrevocably designate this contribution as a
trustee-to-trustee transfer contribution.
*Customer Signature *Date (MM/DD/YYYY)
Excess Contributions: You are not permitted to transfer excess contributions from an HSA, Archer MSA or IRA to a Bank of America
HSA. If any portion of your transfer is or becomes an excess contribution, it is your responsibility to notify Bank of America and
request a withdrawal of the excess contribution together with any net income attributable thereto.
Investments: Your HSA will be invested as provided under your HSA arrangement with Bank of America.
One-time transfer from a Roth or Traditional IRA to an HSA: Generally, only one transfer may be made during the lifetime of an
individual. IRA Transfers count toward and are limited to your maximum HSA contribution for the year.
There are two ways to move funds from an existing HSA, Archer MSA or IRA into a new HSA:
1. Trustee-to-Trustee Transfer: In a trustee-to-trustee transfer the current custodian moves funds to the new custodian directly.
There is no limit under the tax laws on the number of times this can occur.
2. Rollover: A Rollover is a cash distribution and redeposit with another custodian within 60 days. Either the customer receives funds
and re-deposits in a new account or writes a check on an old account to a new custodian. The customer is limited to using this
approach once every 12 months. Bank of America provides HSA Rollover forms online at myhealth.bankofamerica.com under the
“Tools & Resources” tab.
click to sign
click to edit
Comparison of a trustee-to-trustee transfer and a rollover and into a Bank of America HSA*
Trustee-to-Trustee Transfer Rollover
Permitted frequency Unlimited One rollover per 12 month time period, per HSA.
The rollover redeposit with Bank of America must
be completed within 60 days aer the day the
distribution is made. If you fail to redeposit within
this 60-day period, your distribution will be taxable
to you and will be subject to additional penalty
taxes (unless an exception applies).
Tax reporting None required Bank of America is required to report the
contribution on Form 5498-SA.
Fees Bank of America does not charge any fees with a
trustee-to-trustee transfer of funds into the HSA.
Other custodians may charge fees associated with
account closure and/or a trustee-to-trustee transfer.
Bank of America does not charge any fees with a
rollover of funds into the HSA.
Other custodians may charge fees associated with
account closure and/or funds rollover.
*Bank of America Health Benefit Solutions does not provide tax or legal advice. This summary is provided solely for general
information purposes, and is not to be construed as tax or legal advice. Please consult with your own attorney or tax advisor to
understand the tax and legal consequences of your HSA and your particular situation.
Health Savings Account
Transfer Request Form (cont’d)
Bank of America, N.A. Member FDIC. ©2016 Bank of America Corporation | 00-09-1302EV1.BSB | 09/2016