Hsa Distribution Request Form - Hsa Department printable pdf download

HSA Distribution Request Form

Request HSA Distributions Online!

You can request your HSA distribution online at

No need to complete this form if you request your distribution online.

HSA Owner Information:

Company Name ___________________________________________________________________________________________

Account Owner Name __________________________________________

Social Security # ________________________

Address ____________________________________________________________________________________________________

City _______________________________________________________

State __________

Zip ________________________

Phone (_______)_______________________

Email ______________________________________________________________

Please check here if this is a new address

This distribution will be coded as a normal HSA distribution. For death or disability distributions, transfers/rollovers, or to

correct an excess contribution, please contact Alliance Benefit Group to request a different form.

Amount of requested distribution $_______________

Date of distribution request ____/ ____/ __________

I certify that I am the HSA Accountholder or an individual authorized to execute this transaction. I have read and understand the

instructions and any rules or conditions relating to this transaction. I assume full responsibility for this transaction and will not hold Alliance

Benefit Group North Central States, Inc. (TPA) or Healthcare Bank, a division of Bell State Bank & Trust (Trustee/Custodian) liable for any

adverse consequences that may result. I have not received tax or legal advice from Alliance Benefit Group North Central States, Inc. or

Healthcare Bank and, if necessary, will seek the advice of a tax or legal professional to ensure my compliance with related laws. All

information provided by me is true and correct and may be relied upon by Alliance Benefit Group North Central States, Inc. and

Healthcare Bank.

______________________________________________________________________________

Signature of HSA Owner

Submit this request to:

Alliance Benefit Group

Attn: HSA Department

PO Box 1226

Albert Lea, MN 56007

Fax:

1-866-808-7823 (toll-free)

Email:

Note: The minimum distribution amount is $5.00. Incomplete request forms will be returned unprocessed. Please do not include receipts or

statements for medical expenses with your request form – save this documentation for your own records.

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Hsa Distribution Request Form - Hsa Department