Health Savings Account Distribution Request Form

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Health Savings Account
Distribution Request Form
HSA Owner Information:
Company Name ___________________________________________________________________________________________
Account Owner Name ________________________________________
Social Security Number ________________________
Address _________________________________________________________________________________________________
City _____________________________________________________
State __________
Zip ________________________
Phone (_______)_______________________
Email ____________________________________________________________
Please check here if this is a new address
Distribution Information:
 Normal distribution
 Disability
 Death
Amount of requested distribution $_______________
Date of distribution request ____/ ____/ __________
I herby authorize the Custodian and Record Keeper to perform the above transaction on behalf of my HSA. I certify that all information provided by
me is true and accurate. I understand that I am responsible for any consequences resulting from this transaction, including any imposed tax and/or
penalties. I agree that the Custodian and Record Keeper shall in no way be held responsible. I further certify that I have not received any tax or legal
advice from the Custodian or Record Keeper. Should the balance of my HSA be invested in more than one of the available investment options, I
.
understand that funds for this payment will be distributed from all applicable investments on a pro-rata basis by investment balance
_______________________________________________________________________
Signature of HSA Owner
Date
Submit this request to ABG at:
Alliance Benefit Group
Attn: HSA Department
PO Box 1226
Albert Lea, MN 56007
1-866-808-7823 (toll-free fax)
Online Claims:
You also have the option to request your HSA distribution online at
It is not necessary to complete this form when requesting your distribution online.
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.
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