Transfer request form
Email, mail or fax completed forms to:
Email:
transfer@healthequity.com
Address: HealthEquity,An:Operaons
15 W Scenic Pointe Dr, Ste 100, Draper, UT 84020
Fax: 801.846.2929
Use the transfer request form to transfer monies directly from another custodian into your HealthEquity® health savings account (HSA).
Part I—Primaryaccountholderinformaon *Required elds
Last name
*
First name
*
M.I. Gender
c
Male
c
Female
Date of birth
*
Street address
*
City
*
State
*
ZIP
*
Email address Dayme phone
( )
SSN or HealthEquity ID number
*
Employer name Health insurance company Coverage level
c
Single
c
Family
Deducble amount
$
PartII—Transferinformaon
This request is for a custodian-to-custodian transfer or an employer-to custodian transfer. The monies currently held by another custodian are to
be directly transferred to an HSA at HealthEquity. Note: Your current custodian may require addional informaon prior to sending HealthEquity
the funds you are requesng. Please contact them to verify the addional informaon they may need.
Current custodian/Financial instuon
*
Current custodian fax
( )
Dayme phone
( )
Address City State ZIP
Current HSA/IRA/MSA account number Amount to transfer
c
Specific amount $
c
Full amount (close my account)
Please indicate the account type that the monies will be coming from. (See rules and conditions for account types below.)
c
IRA
1
(individual retirement account)
c
MSA
2
(medical savings account)
c
Another HSA
2
(health savings account)
Currentcustodianinstrucons
Make check payable to HealthEquity and mail it to: HealthEquity,An:Operaons, 15 W Scenic Pointe Dr, Ste 100, Draper, UT 84020
Authorizaon
I authorize the transfer of assets in the manner described above and cerfy that all of the informaon provided by me is true and complete.
This transfer request may close my exisng account dened in the Amount to Transfer secon.
I authorize HealthEquity to open a Health Savings Account in my behalf and I accept the terms of the HealthEquity HSA Custodial Agreement
available at hp://resources.healthequity.com/Forms/Agreements/HealthEquity_Custodial_Agreement.pdf. I understand that in compliance with
the USA Patriot Act, HealthEquity must verify the identy of all individuals who seek to open an HSA. I understand that as part of this identy
vericaon process, I may be asked to provide addional informaon and/or documentaon before my account can be established.
Account holder signature
*
Date
Transfers
1
IRA—Beginning in 2007, individuals can make one lifetime transfer from their IRA to an HSA, subject to the contribution limits applicable for
the year of the transfer. Additional information can be found at www.irs.gov.
2
HSA/MSA—If you instruct the custodian of your HSA or MSA to transfer funds directly to the custodian of another HSA, the transfer is not
considered a rollover. There is no limit on the number of these transfers. You do not need to include the amount transferred in income, deduct
it as a contribution, or include it as a distribution on IRS Form 8889, line 12a.
Transfer_request_form_20190809
www.HealthEquity.com
866.346.5800
Move It. Double It.
Get double interest on your HealthEquity® HSA. Just transfer or roll
over $250 or more from another HSA to HealthEquity and get up to
$25 total. Get full details at www.healthequity.com/double-it.
