Health Savings Account (Hsa) Distribution Reversal Form

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Health Savings Account (HSA)
Distribution Reversal Form
Instructions: Complete this form to return a mistaken distribution to your HSA.
Mail completed form with check payable to “FPS Trust” to:
FPS Trust on behalf of HealthSavings
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
____________________________________________________________________
_____________________
__________________________
Social Security Number ________ – ______ – ______________
Account Number ________________________________________
OR
Distribution
InformationRequirements
Amount of mistaken distribution: $_________________
Year of mistaken distribution: _____________
(yyyy)
NOTE: Distribution reversals must be deposited to your account by the tax-filing deadline for the year in which the original
distribution occurred (typically April 15 of the following year), NOT including extensions. If no year is specified, your distribution
reversal will be deposited for the year in which it was received.
Signature
By my signature below I swear or affirm that this deposit, in the amount stated above, to my health savings account (HSA) is
repayment of a mistaken distribution or distributions as defined by the Internal Revenue Service (resulting from a mistake of fact due
to reasonable cause). I understand that I am solely responsible for any tax consequences and penalties of improper reporting of this
deposit as repayment of a mistaken distribution, instead of a contribution, to my HSA.
__________________________________________________________
______ / ______ / ____________
Account Holder Signature
Date
(mm|dd|yyyy)
Rev. 12/2015
10800 Midlothian Turnpike, Suite 240
Richmond, VA 23235
(p) 888.354.0697
(f) 804.726.1570

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