Get the free HSA Distribution Form - Principal Trust Company

Mailing Address: Health Saving Account Distribution Request Form P.O. Box 8963 Wilmington, DE 19899-8963 800-209-9010 Fax: 302-999-9554 1. Account Holder Information (Please Print) Name: Address:

How to fill out hsa distribution form

How to fill out an HSA distribution form:

1. Review the instructions: Before starting to fill out the HSA distribution form, carefully read the instructions provided by your HSA provider. These instructions will outline the necessary steps and requirements for completing the form correctly.
2. Provide personal information: Begin by filling in your personal information, such as your name, address, social security number, and HSA account number. Make sure to double-check the accuracy of the information before proceeding.
3. Specify the distribution type: Indicate the type of distribution you are requesting from your HSA. Common types include a regular distribution for qualified medical expenses, a rollover to another HSA, or a transfer to a different account. Choose the appropriate option and provide any additional details required.
4. Document the distribution amount: Clearly state the amount you wish to distribute from your HSA. It may be helpful to refer to your HSA account balance or consult with your HSA provider to ensure you accurately report the desired distribution amount.
5. Outline the purpose of the distribution: Explain the reason for requesting the distribution. This could include covering medical expenses not covered by insurance, reimbursing yourself for qualified medical expenses already paid for out of pocket, or any other qualified purpose allowed by the IRS.
6. Include required supporting documentation: Attach any necessary supporting documentation with your HSA distribution form. This may include receipts, invoices, or other documentation proving the expenses being claimed as qualified medical expenses. Ensure all documents are legible, organized, and properly labeled.
7. Sign and date the form: Verify that all the required fields are complete and accurately filled out. Then, sign and date the form in the designated area. If you have a joint HSA account, ensure all account holders have signed the form if necessary.

Who needs an HSA distribution form?

1. Individuals with Health Savings Accounts (HSAs): HSA distribution forms are typically required by individuals who have an HSA account. These accounts are often offered in conjunction with high-deductible health insurance plans and allow individuals to save and invest funds for future qualified medical expenses.
2. Those intending to make withdrawals from their HSA: If you are planning to withdraw funds from your HSA for qualified medical expenses or other approved purposes, you will likely need to fill out an HSA distribution form. This form serves as a request to withdraw funds from your HSA account.
3. Individuals seeking to transfer or rollover HSA funds: If you wish to transfer or rollover funds from your HSA to another account, such as another HSA or an IRA, an HSA distribution form will often be required to initiate the process. This form ensures the proper documentation and compliance with IRS rules governing HSA transactions.

Note: It is important to consult with your HSA provider or tax advisor to understand the specific requirements and procedures for filling out an HSA distribution form, as they may vary depending on the provider and individual circumstances.

For pdfFiller’s FAQs

How do I modify my hsa distribution form in Gmail?

Using pdfFiller's Gmail add-on, you can edit, fill out, and sign your hsa distribution form and other papers directly in your email. You may get it through Google Workspace Marketplace. Make better use of your time by handling your papers and eSignatures.

How do I make edits in hsa distribution form without leaving Chrome?

Install the pdfFiller Google Chrome Extension in your web browser to begin editing hsa distribution form and other documents right from a Google search page. When you examine your documents in Chrome, you may make changes to them. With pdfFiller, you can create fillable documents and update existing PDFs from any internet-connected device.

Can I create an electronic signature for the hsa distribution form in Chrome?

Yes, you can. With pdfFiller, you not only get a feature-rich PDF editor and fillable form builder but a powerful e-signature solution that you can add directly to your Chrome browser. Using our extension, you can create your legally-binding eSignature by typing, drawing, or capturing a photo of your signature using your webcam. Choose whichever method you prefer and eSign your hsa distribution form in minutes.

What is hsa distribution form?

HSA distribution form is a form used to report distributions from a Health Savings Account (HSA).

Who is required to file hsa distribution form?

Individuals who have taken distributions from their HSA are required to file the HSA distribution form.

How to fill out hsa distribution form?

To fill out the HSA distribution form, individuals need to provide information about the distributions they have taken from their HSA, including the amount and purpose of the distribution.

What is the purpose of hsa distribution form?

The purpose of the HSA distribution form is to report distributions from an HSA and ensure that taxes are properly paid on those distributions.

What information must be reported on hsa distribution form?

The HSA distribution form must include information about the amount of the distribution, the purpose of the distribution, and any taxes that were withheld.