Hsa Distribution Form - Horizon Trust

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HSA WITHDRAWAL AUTHORIZATION
Refer to page 2 for reporting information
Horizon Trust Company | P.O. Box 30007 , Albuquerque, New Mexico 87190
MAILING ADDRESS:
Horizon Trust Company | 10600 Menaul Blvd. N.E., Albuquerque, New Mexico 87112
FOR OVERNIGHT NIGHT MAIL ONLY:
PART 1. HSA OWNER
PART 2. IRA TRUSTEE OR CUSTODIAN
To be completed by the HSA Trustee or custodian
Name (First/MI/Last)
Name
Social Security Number
Address Line 1
Date of Birth
Phone
Address Line 2
Email Address
City/State/Zip
Account Number
Suffix
Phone
Org. No
PART 3. BENEFICIARY OR FORMER SPOUSE
PART 4. WITHDRAWAL INFORMATION
INFORMATION
Total Withdrawal Amount
Address Line 1
Withdrawal Date
Withdrawal Reason (select one)
Address Line 2
Transfer to Another HSA
Normal Withdrawal
City/State/Zip
Disability
Prohibited Transaction
Tax ID (SSN/TIN)
Excess Contribution Removed Before the Excess Removal Deadline
Date of Birth
Phone
Net Income Attributal to Excess
Beneficiary Type (select one if applicable)
Excess Contribution Removed After the Excess Removal Deadline
Death Withdrawal by a Beneficiary Taken in the Year of Death
Spouse
Estate
Other
Death Withdrawal by a Beneficiary Taken After the Year of Death
PART 5. WITHDRAWAL INSTRUCTIONS
ASSET HANDLING
(Assets identified below will be liquidated immediately unless otherwise specified in the Special Instructions section.)
Asset Description
Amount to be Withdrawn
Special Instruction
PAYMENT METHOD
Cash
Check (If the withdrawal reason is a transfer to another HSA, the check must be made payable to the receiving organization.)
Make payable to __________________________________________________________________________________________________________
Internal Account Account Number _____________________________________ Type (e.g., checking, savings) _________________________
External Account (e.g., EFT, ACH, wire) (Additional documentation may be required and fees may apply.)
Name of Organization Receiving the Assets ______________________________ Routing Number (Optional) ___________________________
Account Number ____________________________________________________ Type (e.g., checking, savings) _________________________

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