Fillable WITHDRAWAL AUTHORIZATION (Georgia's Own Credit Union)

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WITHDRAWAL AUTHORIZATION (Georgia's Own Credit Union)

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Page 1 of 2
3314 / 2606H (Rev. 4/2015) ©2015 Ascensus, Inc.
WITHDRAWAL AUTHORIZATION
Refer to page 2 for reporng informaon.
PART 1. HSA OWNER
Name (First/MI/Last) _________________________________________
Social Security Number _______________________________________
Date of Birth ____________________ Phone _____________________
Email Address _______________________________________________
Account Number__________________________________ Sux _____
PART 2. HSA TRUSTEE OR CUSTODIAN
To be completed by the HSA trustee or custodian
Name _____________________________________________________
Address Line 1 ______________________________________________
Address Line 2 ______________________________________________
City/State/ZIP _______________________________________________
Phone________________________ Organizaon Number ___________
PART 5. WITHDRAWAL INSTRUCTIONS
ASSET HANDLING (Assets idened below will be liquidated immediately unless otherwise specied in the Special Instrucons secon.)
AssetDescripon AmounttobeWithdrawn SpecialInstrucons
__________________________________________ ______________________ ____________________________________________________________________
__________________________________________ ______________________ ____________________________________________________________________
__________________________________________ ______________________ ____________________________________________________________________
PAYMENT METHOD
Cash
Check(If the withdrawal reason is a transfer to another HSA, the check must be made payable to the receiving organizaon.) 
Make payable to __________________________________________________________________________________________________________
InternalAccount
Account Number _____________________________________________ Type (e.g., checking, savings, HSA) _______________________________
ExternalAccount (e.g., EFT, ACH, wire) (Addional documentaon may be required and fees may apply.)
Name of Organizaon Receiving the Assets ___________________________________________ Roung Number (Oponal) _________________
Account Number _____________________________________________ Type (e.g., checking, savings, HSA) _______________________________
PART 3. BENEFICIARY OR FORMER SPOUSE INFORMATION
This secon should only be completed by a beneciary taking a death
withdrawal or a former spouse taking a withdrawal as a result of a court-
approved property selement due to divorce or legal separaon.
Name (First/MI/Last) _________________________________________
Address Line 1 ______________________________________________
Address Line 2 ______________________________________________
City/State/ZIP _______________________________________________
Tax ID (SSN/TIN) _____________________________________________
Date of Birth________________________ Phone __________________
BENEFICIARY TYPE (Select one, if applicable)
Spouse    Estate    Other
PART 4. WITHDRAWAL INFORMATION
Total Withdrawal Amount _____________________________________
Withdrawal Date _____________________________________________
This Withdrawal Will Close This HSA
WITHDRAWALREASON(Select one)
1. Transfer to Another HSA
2. Normal Withdrawal
3. Disability
4. Prohibited Transacon
5. Excess Contribuon Removed Before the Excess Removal Deadline
Net Income Aributable to Excess _________________________
6. Excess Contribuon Removed Aer the Excess Removal Deadline
7. Death Withdrawal by a Beneciary Taken in the Year of Death
8. Death Withdrawal by a Beneciary Taken Aer the Year of Death
PART 6. SIGNATURES
I cerfy that I am authorized to receive payments from this HSA and that all informaon provided by me is true and accurate. No tax advice has been
given to me by the trustee or custodian. All decisions regarding this withdrawal are my own, and I expressly assume responsibility for any
consequences that may arise from this withdrawal. I agree that the trustee or custodian is not responsible for any consequences that may arise from
processing this withdrawal authorizaon.
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 Trustee or Custodian Date (mm/dd/yyyy)
Page 2 of 2
3314 / 2606H (Rev. 4/2015) ©2015 Ascensus, Inc.
REPORTING INFORMATION APPLICABLE TO HSA WITHDRAWALS
You must supply all requested informaon for the withdrawal so the trustee or custodian can properly report the withdrawal.
If you have any quesons regarding a withdrawal, please consult a competent tax professional or refer to IRS Publicaon 969, Health Savings
Accounts and Other Tax-Favored Health Plans, for more informaon. This publicaon is available on the IRS website at www.irs.gov or by calling
1-800-TAX-FORM.
WITHDRAWALREASON
HSA assets can be withdrawn at any me. Most HSA withdrawals are reported to the IRS. IRS rules specify the distribuon code that must be used to
report each withdrawal on IRS Form 1099-SA, Distribuons From an HSA, Archer MSA, or Medicare Advantage MSA.
TransfertoAnotherHSA. Transfers are not reported on Form 1099-SA. Transfers may be made by an HSA owner or former spouse under a transfer
due to a divorce.
NormalWithdrawal. Normal withdrawals are reported on Form 1099-SA using code 1. Also use code 1 if no other code applies to the withdrawal.
Disability. Disability withdrawals are reported on Form 1099-SA using code 3.
ProhibitedTransacon. Prohibited transacons as dened in Internal Revenue Code Secon 4975(c) are reported on Form 1099-SA using code 5.
ExcessContribuonRemoval. Excess contribuons removed before the excess removal deadline (your tax ling deadline, including extensions) must
include the net income aributable to the excess. A removal of an excess contribuon is reported on Form 1099-SA using code 2.
DeathWithdrawalbyaBeneciaryTakenintheYearofDeath. If the nancial organizaon is noed of the HSA owner’s death and the withdrawal
is made to the beneciary in a year of death, the Form 1099-SA reporng code depends on the type of beneciary.
• If the beneciary is a spouse, the withdrawal is reported on Form 1099-SA using code 1.
• If the beneciary is an estate or other, the withdrawal is reported on Form 1099-SA using code 4.
DeathWithdrawalbyaBeneciaryTakenAertheYearofDeath. If the nancial organizaon is noed of the HSA owner’s death and the
withdrawal is made to the beneciary in a year aer the year of death, the Form 1099-SA reporng code depends on the type of beneciary.
• If the beneciary is a spouse, the withdrawal is reported on Form 1099-SA using code 1.
• If the beneciary is an estate, the withdrawal is reported on Form 1099-SA using code 4.
• If the beneciary is other, the withdrawal is reported on Form 1099-SA using code 6.
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WITHDRAWAL AUTHORIZATION (Georgia's Own Credit Union)

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Completed 23 December 2020

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