The Hsa Return Of Mistaken Distribution Form - Educators Credit Union

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School District of Waukesha – Health Savings Account at Educators Credit Union
HSA Distribution Correction Worksheet
Name: _______________________________________________________________________________________
SSN/TIN: ___________________________________________________________________________________
Educators HSA #: ______________________________________
Please contact me by phone/email (circle one) if there are questions. My contact information is:
Home Phone: _____________________________________________
Cell Phone: ____________________________________________________
Email Address: _____________________________________________________________________________
Health Savings Account Distribution Needing Correction:
Date of Distribution: __________________________________
Dollar Amount of Distribution: _________________________
Merchant Name: _____________________________________________________________________________________________________________
Redeposit Date: _________________________________________
By signing below, I confirm that the above-listed distribution taken from my Health Savings Account at
Educators Credit Union was done in error and that I have redeposited the mistaken distribution into the
HSA. I understand that the mistaken distribution will not be reported on IRS Form 1099-SA and the
redeposited amount will not be reported on IRS Form 5498-SA.
Member Signature: ___________________________________________________________________ Date: _________________________
Return completed form to Educators Credit Union:
Fax to: Educators Credit Union - Attn: Rachel Lempesis - Fax #: 262-884-7235
In Person: Waukesha Branch located at 1600 Summit Avenue – Suite A, Waukesha, WI 53188
**Form to be forwarded to IRA Department – Attn: Rachel Lempesis**
Office Use Only
Date Received
Received by User #
Date Corrected
Corrected by User #

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