Health Savings Account (Hsa) Death Distribution Request Form

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Health Savings Account (HSA)
Death Distribution Request Form
Instructions:
1. Use this form to authorize a distribution of assets from a decedent’s HSA directly to you as the beneficiary or
executor.
2. Complete all sections of this form, attach a certified copy of the death certificate and mail completed form to:
Health Savings Administrators
10800 Midlothian Turnpike, Suite 240 • Richmond, VA 23235
Account Holder Information
(Beneficiary/executor completes this section with HSA account holder
information)s
First Name ________________________________________ Last Name __________________________________________ M.I. ________
Social Security Number ________ – ______ – ______________
Beneficiary Information
(Beneficiary completes this section with his/her information)
Beneficiary listed below must match beneficiary information contained in the HSA account holder’s profile.
Please Select Beneficiary Type:
q
Spouse
q
Non-Spouse
q
Estate — A copy of the Letter of Testamentary is required to validate executorship.
First Name ________________________________________ Last Name __________________________________________ M.I. ________
Street Address _________________________________________________________________________ Apt / Suite ___________________
City
State
ZIP Code
____________________________________________________________________
_____________________
__________________________
Social Security Number ________ – ______ – ______________
Date of Birth
______ / ______ / ____________
(mm|dd|yyyy)
Telephone Number _________________________________ Driver’s License Number ___________________________________________
Processing Option (Please choose only one)
q
I am the spouse and I am requesting the account to remain an HSA account. By completing this section:
>
I confirm that I have successfully created an account on
or have an existing account in my name.
>
I request to have the HSA funds remaining in my spouse’s account transferred to my account.
q
I am the spouse and I am requesting payout and closing of my husband’s/wife’s HSA account. Amounts distributed will
generally be included in my gross income, except for any amount used to pay for medical expenses I incur before the distribution
date or medical expenses that were incurred by my spouse before death (and paid by me within one year after the date of death).
q
I am a non-spousal beneficiary requesting payout. I am required to include the funds received in my gross income, except for
any amount used to pay for medical expenses incurred by the HSA account holder (and paid by me within one year of the account
holder’s death).
q
I am the executor of the Estate of the Decedent. If there is no designated beneficiary, the entire amount of the HSA shall be paid
to the estate of the deceased and included on the decedent’s final income tax return.
~ Continued on Page 2 ~
Rev. 01/2015
PAGE | 1
10800 Midlothian Turnpike, Suite 240
Richmond, VA 23235
(p) 888.354.0697
(f) 804.726.1570

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