Health Savings Account Contribution Form (Page 2 of 2) in pdf

Health Savings Account Contribution Form Page 2

R10.15

Health Savings Account (HSA) or Medical Savings Account (MSA)

Contribution Form

UMB Health Savings Account Number

(

10-digit number found on your HSA statement)

I further understand that it is my sole responsibility to determine the tax consequences of such contribution, rollover

or re-deposit, to properly report it on my federal income tax return and on Form 8889 for HSA or Form 8853 for

MSA accounts, as well as on any state income tax returns, and to pay any taxes and penalties arising as a result of this

action (see IRS Publication 969, Health Savings Accounts and other Tax-Favored Health Plans).

ACCOUNT OWNER’S NAME (PLEASE PRINT)

ADDRESS

CITY

STATE

ZIP CODE

HOME PHONE NUMBER

WORK PHONE NUMBER

SOCIAL SECURITY NUMBER

DATE OF BIRTH

Signature of Account Owner

Date

Please ensure you write your HSA account number on your check!

Return completed form to: UMB HSA Processing

P.O. Box 219531

Kansas City, MO 64121-9531

UMB Bank Use Only

Date:

Trans Code:

Description:

Initials:

UMB Bank Routing Number: 101000695

Page 2 of 2

Health Savings Account Contribution Form Page 2