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CONTRIBUTION REQUEST FORM Health Savings Account (HSA)INSTRUCTIONS Complete this form to make a normal, mistaken distribution, rollover or transfer contribution to your BASIC HSA. Enclose a check
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01
Obtain a copy of the HS-6251-041919-TASC-HSA-Contribution-Request-Form from your HSA provider or their website.
02
Fill out your personal information such as name, address, and HSA account number.
03
Indicate the contribution amount you wish to make to your HSA for the current year.
04
Sign and date the form to confirm your request.
05
Submit the completed form to your HSA provider for processing.

Who needs hs-6251-041919-tasc-hsa-contribution-request-form?

01
Individuals who have a Health Savings Account (HSA) and wish to make contributions to it.
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The hs-6251-041919-tasc-hsa-contribution-request-form is a document used to request contributions to a Health Savings Account (HSA) managed by TASC.
Individuals who wish to make contributions to their HSA and want to report those contributions for compliance with tax regulations are required to file this form.
To fill out the form, provide personal information, enter the contribution amount, and ensure all fields are completed accurately according to the instructions provided.
The purpose of the form is to officially request and document contributions made to an HSA for tax benefits and compliance purposes.
The form must report personal identification information, HSA account details, and the total contribution amount being requested.
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