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HEALTH SAVINGS ACCOUNT (HSA) WITHDRAWAL AND REIMBURSEMENT REQUEST FORM *** FAX CLAIM FORM AND RECEIPT(S) TO 8778595736 Name OR EMAIL TO: FLEX NEWPORTGROUP.COM *** Social Sec NumberAddressApt #CityStatePhoneEmailZIPEmployer
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How to fill out withdrawal and reimbursement
How to fill out withdrawal and reimbursement
01
To fill out a withdrawal form:
02
Obtain a withdrawal form from the concerned department or organization.
03
Fill out the top section of the form, providing your personal details such as name, contact information, and identification number.
04
Specify the reason for your withdrawal request, whether it is for personal reasons, medical purposes, or any other applicable category.
05
Indicate the amount you wish to withdraw and provide any necessary supporting documents or proof of eligibility, if required.
06
Review the form thoroughly, ensuring all the information is accurate and complete.
07
Sign and date the form.
08
Submit the filled-out withdrawal form to the designated authority or department, following their specific instructions.
09
Keep a copy of the form for your records.
Who needs withdrawal and reimbursement?
01
Withdrawal and reimbursement are generally needed by individuals who have made an initial deposit or payment to a particular organization or scheme. Common examples include:
02
- Customers who wish to withdraw funds from their bank accounts.
03
- Employees who want to claim reimbursement for expenses incurred on behalf of their company.
04
- Students seeking a refund for tuition fees or other educational expenses.
05
- Patients who are eligible for healthcare reimbursement.
06
- Plan holders who need to withdraw funds from their insurance policies.
07
- Individuals looking to claim refunds for cancelled or unused services or products.
08
- Beneficiaries of government assistance programs or social security who require financial support.
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