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WITHDRAWAL AUTHORIZATION Refer to page 2 for reporting information. PART 1. HSA COUNTERPART 2. HSA TRUSTEE OR CUSTODIANName (First/MI/Last)Name be completed by the HSA trustee or custodian Delta Community

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How to fill out hsa withdrawal authorization

01

Log in to your HSA provider's online portal or contact customer service to request a withdrawal authorization form.

02

Fill out the form with your personal information, including name, account number, and contact details.

03

Indicate the amount you wish to withdraw from your HSA account.

04

Specify the reason for the withdrawal, such as medical expenses or retirement.

05

Sign and date the form, following any additional instructions provided by your HSA provider.

06

Submit the completed form to your HSA provider for processing.

Who needs hsa withdrawal authorization?

01

Anyone who has a Health Savings Account (HSA) and wishes to make a withdrawal from their account needs to fill out a HSA withdrawal authorization form.

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What is hsa withdrawal authorization?

HSA withdrawal authorization is an official form that allows an individual to withdraw funds from their Health Savings Account (HSA).

Who is required to file hsa withdrawal authorization?

Any individual who wishes to withdraw funds from their HSA is required to file a withdrawal authorization form.

How to fill out hsa withdrawal authorization?

To fill out the HSA withdrawal authorization form, one must provide personal information, the amount to be withdrawn, and the reason for the withdrawal.

What is the purpose of hsa withdrawal authorization?

The purpose of the HSA withdrawal authorization is to document and approve the withdrawal of funds from a Health Savings Account.

What information must be reported on hsa withdrawal authorization?

The HSA withdrawal authorization form must include personal information of the account holder, amount to be withdrawn, reason for withdrawal, and any supporting documentation.

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