Fillable Hsa Transfer Request Form (Page 2 of 2) in pdf

Health Savings Account

Transfer to HSA at PayFlex Request Form

Instructions: Complete sections 1, 2 and 3 on this form to transfer an HSA from your current Trustee or Custodian to PayFlex

. Some custodians may

require their own form in addition to this form. Please check with your current Trustee, Custodian or agent for any specific requirements.

Mail this form to the address at the bottom of the page.

Section 1: HSA Account Owner Information – PLEASE PRINT

First Name

Last Name

Social Security Number (Required)

Address Line 1 – Street Address (Do not use a PO Box Address)

Address Line 2

City

State

ZIP Code

E-mail Address

Day-Time Telephone Number

Section 2: Type of Transfer – SELECT ONE OF THE FOLLOWING

HSA to HSA Transfer: I currently have HSA funds with another Trustee or Custodian. I want funds in that HSA transferred to my HSA at

PayFlex.

Archer Medical Savings Account (MSA) to HSA Transfer: I currently have MSA funds with another Trustee or Custodian. I want funds in my

MSA transferred to my HSA at PayFlex.

Individual Retirement Account (IRA) to HSA Transfer: I want to transfer funds from my Traditional or Roth IRA to my HSA at PayFlex. I

understand that this must be a direct trustee-to-trustee transfer. I further acknowledge that due to special requirements as established by the

IRS, this transfer may have certain restrictions and tax consequences. I have or will consult my tax advisor with any questions I have.

Section 3: Transfer Instructions – PLEASE PRINT

Current Trustee or Custodian: Please liquidate and transfer per the instructions below. (This is for the account you are transferring to PayFlex.)

Account Number

Name on Account (should match name in section 1)

Custodian Name and Address

Entire Account Balance (Liquidate and transfer my full account balance available)

(Liquidate and transfer the amount directed)

Section 4: PayFlex HSA Information – TRANSFER INSTRUCTIONS TO RESIGNING CUSTODIAN/AGENT

Please issue check with a copy of this form to:

PayFlex Systems USA, Inc. as Custodian for (Name of Account Owner)

HSA Operations

PO Box 3317

Carol Stream, IL 60132-3317

1-888-678-8242

Certification and Signature

I certify that the information contained on this form is true and correct. I direct the current custodian or trustee (in Section 3, above) to transfer the HSA,

Archer MSA or IRA funds to PayFlex Systems USA, Inc. I have identified the amount for the transfer above. I understand that I am responsible for any

tax consequences of this action. I indemnify and hold PayFlex, its agents and affiliates, harmless from any resulting liabilities. PayFlex Systems USA,

Inc. shall accept the transferred funds as a transfer to the HSA of the Account Owner and immediately deposit the funds.

HSA Account Owner Signature

Date

Acceptance by PayFlex Systems USA, Inc. – TO BE COMPLETED BY PAYFLEX

PayFlex Systems USA, Inc. (PayFlex) is willing to accept HSA, MSA or IRA funds that the current trustee or custodian holds in accordance with the

above instructions. The Account Owner, by his or her signature above, hereby directs the current trustee or custodian to transfer assets maintained

with the current trustee or custodian, in the amount of the requested distribution set forth above and, after deduction of any necessary fees and

expenses, to PayFlex at the address above (Section 4). Transfers to PayFlex must be in cash equivalents. PayFlex does not accept “in-kind” transfers

of mutual funds or stock.

Accepted by PayFlex (Authorized PayFlex Representative)

Date

Mail this form to: PayFlex Systems USA, Inc., HSA Operations, 13511 Label Lane, Ste 201, Hagerstown MD 21740

PF-16 (6-15) A

Hsa Transfer Request Form Page 2

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