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(R 03/12) Health Savings Account (HSA) Excess Contribution Withdrawal Request As Owner of the Health Savings Account identified below, I hereby request that the Custodian take the following action:

How to fill out hsa closurewithdrawal request

How to fill out an HSA closure/withdrawal request:

1. Start by obtaining the necessary forms from your HSA provider. These forms may be available online or you may need to request them directly from the provider.
2. In the form, you will typically need to provide your personal information such as your full name, contact information, and HSA account number. Make sure to fill in these details accurately.
3. The form may require you to specify the reason for closing or withdrawing from your HSA. Common reasons include medical expenses, retirement, or a change in employment. Select the appropriate reason that applies to your situation.
4. If applicable, indicate the amount you wish to close or withdraw from your HSA. Some HSA closure/withdrawal forms may require you to state the exact dollar amount while others may provide options like “maximum allowable” or “remaining balance.”
5. You may be required to provide additional documentation to support your closure/withdrawal request depending on the reason stated. This could include medical bills, retirement documents, or employment verification.
6. Once you have completed the form and attached any necessary documentation, review the information to ensure accuracy and completeness. Check for any errors or missing details before submitting the request.
7. Depending on your HSA provider's instructions, you may need to mail or email the completed form and supporting documents to the designated address or email address. Follow the instructions provided to properly submit your closure/withdrawal request.

Who needs an HSA closure/withdrawal request?

1. Individuals who no longer wish to participate in a Health Savings Account (HSA) may need to submit an HSA closure/withdrawal request. This could be due to a variety of reasons such as changing health insurance plans or no longer being eligible for an HSA.
2. Those who have incurred qualifying medical expenses and want to withdraw funds from their HSA to cover those expenses may need to file a closure/withdrawal request. This allows them to access the funds accumulated in their HSA.
3. Individuals who have reached retirement age and want to withdraw funds from their HSA as a part of their retirement planning may need to submit an HSA closure/withdrawal request.
4. Employees who have experienced a change in employment or are no longer eligible for an HSA through their employer may need to fill out a closure/withdrawal request to close their account or transfer the funds to a different HSA provider.

Note: The specific requirements for an HSA closure/withdrawal request may vary depending on the HSA provider and individual circumstances, so it is important to carefully review the instructions provided by your HSA administrator.

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What is hsa closurewithdrawal request?

The hsa closurewithdrawal request refers to a form that is submitted to close or withdraw funds from a Health Savings Account (HSA).

Who is required to file hsa closurewithdrawal request?

Any individual who wishes to close or withdraw funds from their Health Savings Account (HSA) is required to file the hsa closurewithdrawal request.

How to fill out hsa closurewithdrawal request?

To fill out the hsa closurewithdrawal request, you need to provide your personal information, HSA account details, the amount you wish to close/withdraw, and any required supporting documentation. The specific process may vary depending on your HSA provider.

What is the purpose of hsa closurewithdrawal request?

The purpose of the hsa closurewithdrawal request is to initiate the closure or withdrawal of funds from a Health Savings Account (HSA) as requested by the account holder.

What information must be reported on hsa closurewithdrawal request?

The hsa closurewithdrawal request typically requires the account holder to report their personal information (name, address, SSN), HSA account details, the amount to be closed/withdrawn, and any necessary supporting documentation.

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