Health Savings Account
Transfer Request Form (cont’d)
Step 3: Instructions to the Transferring Trustee/Custodian
3a) Originating Account Type:
HSA Archer MSA IRA
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)
IMPORTANT INFORMATION
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.
GENERAL INFORMATION
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.
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