Health Savings Account (Hsa) Death Distribution Request Form (Page 2 of 2) in pdf

Health Savings Account (Hsa) Death Distribution Request Form Page 2

Health Savings Account (HSA)

Death Distribution Request Form

Rules, Conditions & Signature

Checks will be issued and mailed to the address provided on page one. To help the government fight the funding of terrorism and

money laundering activities, federal law requires all financial institutions to obtain, verify and record information that identifies any

person to whom funds are being distributed prior to completing the distribution. If the HSA consists of mutual funds, these funds will

be liquidated and transferred/distributed as cash. FPS Trust reserves the right to complete this liquidation at such time that is reasonable

upon receipt and verification of this form. Due to the important tax consequences relating to the death of an HSA account holder, I have

been advised to see a tax professional. State tax laws may vary, and I agree that FPS Trust makes no representation as to the tax effect

of this distribution under state or federal law. The information provided is in general terms only to provide some information relating to

the tax consequences of a decedent’s HSA account.

Information provided by me is true and correct and may be relied upon by FPS Trust. I assume full responsibility for this transaction and

will not hold FPS Trust liable for any adverse consequences that may result.

I am the individual authorized to execute this transaction. I have read and understand the instructions, rules and conditions

relating to this transaction.

______________________________________________________________

______ / ______ / ____________

HSA Beneficiary Signature

Date

(mm|dd|yyyy)

Rev. 01/2015

PAGE | 2

10800 Midlothian Turnpike, Suite 240

Richmond, VA 23235

(p) 888.354.0697

(f) 804.726.1570

Health Savings Account (Hsa) Death Distribution Request Form Page 2