Health Savings Account Contribution Form

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R10.15
Health Savings Account (HSA) or Medical Savings Account (MSA)
Contribution Form
UMB Health Savings Account Number
9
8
(
10-digit number found on your HSA statement)
As owner of the Health Savings Account/Medical Savings Account as identified above,
I hereby request that the custodian take the following action: (Please check one action below)
Deposit — Regular Contribution
I am making an account contribution/deposit in the amount of $
Current Tax Year
 Contribution Type 
Employee (UMB Code 0,1005) 
Employer (UMB Code 2,6371)
Prior Tax Year
   Contribution Type 
Employee (UMB Code 1,6345) 
Employer (UMB Code 7,6369)
(You can have your contribution deposited under the prior plan year if your contribution is received between Jan 1 and Apr 15
and you have not completed your tax filing for the year.) All prior year contributions must be postmarked by April 15.
NOTE: annual contribution limits apply. Please reference IRS Document 969 for the allowable limit on
contributions that apply.
Redeposit — Return of Mistaken Distribution (money spent from my HSA/MSA in error)
(UMB Code 3,6359)
I am making a redeposit in the amount of $
related to a mistaken distribution
from my account.
By signing the bottom of page 2 of this form, I affirm that this deposit, in the amount stated above, is repayment
of a mistaken distribution as defined by the IRS with no penalty if there is reasonable evidence that the original
distribution was made in good faith (resulting from a mistake of fact due to reasonable cause). The repayment
is classified as a “redeposit”, not a contribution; therefore it would not count toward the yearly maximum
contribution. I understand UMB is not required to accept the mistaken distribution and I am responsible for any
tax consequence that may result from the distribution.
I understand that a distribution reversal or redeposit must be deposited by the tax-filing deadline, excluding
extensions, for the year in which the original distribution occurred (usually April 15 of the following year). This
redeposit will decrease the amount of distributions reported by UMB.
Reason for Redeposit: (Please check appropriate box below)
I received reimbursement for the expense
A claim/distribution was overpaid
from another source
My claim was reprocessed and I had
I paid an expense that was not HSA/MSA qualified
a bill adjustment
Rollover Contribution — Rollover from another HSA or MSA
(UMB Code 4,6365)
I am making a rollover contribution in the amount of $
. I understand that I can
rollover amounts from Archer MSAs and other HSAs into an HSA. I must roll over the amount within 60 days
after the date of receipt. I can make only one rollover contribution to an HSA/MSA during a 1-year period. A
rollover contribution is not included in my income, is not deductible, and does not affect my contribution limit.
NOTE: If you instruct the trustee of your HSA/MSA to transfer funds directly to UMB, the transfer is not
considered a rollover. Use a “Transfer to UMB from Other Trustee Form” for this purpose, not this form.
Please ensure you write your HSA account number on your check!
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