Health Savings Account (Hsa) Contribution Form
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1Health Savings Account (HSA)
Contribution Form
Instructions: Complete this form to make a contribution to your account. Make checks payable to FPS Trust. You
can also make contributions online at
.
Mail completed form with check
FPS Trust on behalf of
payable to “FPS Trust” to:
HealthSavings Administrators
P .O. Box 3079
Englewood, CO 80155
Account Holder Information
Requirements
First Name ________________________________________ Last Name __________________________________________ M.I. ________
Street Address _________________________________________________________________________ Apt / Suite ___________________
City
State
ZIP Code
____________________________________________________________________
_____________________
__________________________
(Health Savings Account Number or full Social Security Number required)
Social Security Number* ________ – ______ – ______________
OR
Account Number* ______________________________________
*Please include your account number or Social Security number on your check.
Contribution Information
Contribution Amount: $_________________
Contribution for:
q
q
Current Year_____________
OR
Prior Year_____________
(yyyy)
(yyyy)
NOTE: Prior year deposits must be received by April 15th. The IRS does NOT allow an extension of time to contribute to an
HSA, even if you have an extension for filing your taxes. If a year is not specified, your contribution will be deposited for the
year in which it was received.
Check Total: $_________________
Contribution Source:
q
Account holder and/or family member
q
Employer
q
Employee pre-tax (through Section 125 Plan)
NOTES:
>
Deposits may not be available for immediate withdrawal.
>
Funds will be allocated to your account based on your current elections. To review or update your elections, log into your
account at After logging in, go to INVESTING > INVESTMENT DIRECTION > ELECTIONS.
>
Please do not include your annual administrative fee with your contribution.
>
To view the annual contribution limits, visit .
_____________________________________________________________
______ / ______ / ____________
Account Holder Signature
Date
(mm|dd|yyyy)
Rev. 03/2016
10800 Midlothian Turnpike, Suite 240
Richmond, VA 23235
(p) 888.354.0697
(f) 804.726.1570
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