Form Wp 11561 - Mistaken Distribution Form - Hsa - Michigan

ADVERTISEMENT

Mistaken Distribution Form
Personal information
Account number: ___________________________________
Name: ______________________________________________________________________________________________________
First
Last
Middle initial
Address: ____________________________________________________________________________________________________
Street
City
State
ZIP
Phone: (______) ______________________________________ Email __________________________________________________
Account holder Social Security number: ________________________________________________________________________
Distribution information
Amount of mistaken distribution
Year of mistaken distribution
________________________________
________________________
I certify that the above distribution was the result of a mistake of fact and I authorize Blue Cross Blue Shield of Michigan to
redeposit the distribution as a mistaken distribution.
I understand Blue Cross Blue Shield of Michigan is not required to accept the mistaken distribution and I am responsible for
any tax consequences that may result from the distribution.
Banking information
How would you like to redeposit the funds into your HSA?
Option 1:
Option 2:
Check
One time electronic funds transfer
q
q
Include a check (payable to HealthEquity,
Fax this form and a voided check to: 801-727-1005
Inc.) with this form.
Financial institution: ________________________________
Mail to:
City/State: ________________________________________
HealthEquity, Inc.
Routing number: ___________________________________
15 West Scenic Pointe Drive, Suite 400
Draper, UT 84020
Account number: __________________________________
Signature
By signing below, I swear or affirm that this deposit, in the amount stated above, to my health savings account 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.
___________________________________________
_________________________________________
___________________
Print name
Signature
Date
Mail or fax completed forms with voiced check to:
CDH Administrator
15 West Scenic Pointe Drive, Suite 400
Draper, UT 84020
Fax: 520-844-7090
HealthEquity, Inc. is an independent company partnering with Blue Cross Blue Shield
of Michigan to provide health care spending account administration services. An
independent and FDIC-insured bank holds the health savings account dollars.
Blue Cross Blue Shield of Michigan is a nonprofit corporation and independent licensee of the Blue Cross and Blue Shield Association.
WP 11561 DEC 12
R011555

ADVERTISEMENT

00 votes

Related Articles

Related forms

Related Categories

Parent category: Financial
Go