Get the free HSA Reverse Distribution Request - Union Bank & Trust

HEALTH BENEFIT SOLUTIONS HSA Reverse Distribution Request Please complete this form if you withdrew funds from your HSA account to make a purchase and would like those funds returned to your HSA account.

How to fill out hsa reverse distribution request

How to fill out an HSA reverse distribution request:

1. First, gather all the necessary documents: You will need your HSA account information, including your account number and routing number. You may also need to provide proof of a qualifying distribution event, such as medical expenses or disability.
2. Next, locate the HSA reverse distribution request form: Contact your HSA provider to obtain the appropriate form. This form may also be available on the provider's website.
3. Fill out the personal information section: Provide your name, address, date of birth, and social security number. This information is necessary for identification purposes.
4. Provide details about the reverse distribution event: In this section, explain the reason for the reverse distribution request. Specify the date of the event, such as when the medical expenses were incurred or when you became disabled.
5. Calculate the amount of the reverse distribution: Determine the total amount of the distribution you wish to reverse. This may be the full balance of your HSA or a specific amount. Make sure to double-check your calculations to ensure accuracy.
6. Specify the method of distribution: Indicate how you would like to receive the reverse distribution. Common options include a check mailed to your address or a direct deposit into your bank account. Provide the necessary account information if applicable.
7. Read and sign the declaration: Carefully review the declaration section of the form, which typically includes statements regarding the accuracy of the information provided and your understanding of the tax implications. Sign and date the form accordingly.
8. Submit the completed form: Follow the instructions provided by your HSA provider on how to submit the form. This may include mailing it to a specific address or submitting it electronically through their online portal.

Who needs an HSA reverse distribution request?

Individuals who have excess funds in their HSA or need to reverse a distribution made in error may need to submit an HSA reverse distribution request. Excess funds may occur if contributions were made in excess of the annual contribution limit or if funds were deposited into the HSA incorrectly. Additionally, if a distribution was made for a qualifying event that is later determined to be ineligible, a reverse distribution request may be necessary to return the funds to the HSA and avoid penalties. It is important to check with your HSA provider for specific guidelines and eligibility criteria for submitting a reverse distribution request.

For pdfFiller’s FAQs

What is hsa reverse distribution request?

HSA reverse distribution request is a form submitted to request the return of excess contributions or mistaken distributions from a Health Savings Account.

Who is required to file hsa reverse distribution request?

Individuals who have made excess contributions or received mistaken distributions from their HSA are required to file a reverse distribution request.

How to fill out hsa reverse distribution request?

To fill out a HSA reverse distribution request, individuals must provide details about the excess contributions or mistaken distributions, as well as any relevant documentation.

What is the purpose of hsa reverse distribution request?

The purpose of a HSA reverse distribution request is to correct errors or remove excess contributions from an individual's Health Savings Account.

What information must be reported on hsa reverse distribution request?

The reverse distribution request must include details about the excess contributions or mistaken distributions, including the amount, date, and reason for the request.

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