Health Savings Account Distribution Request Form - American Fidelity Health Services Administration

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Toll free: 1-866-326-3600
Phone: (405) 523-5699
Fax: (405) 523-5072
Website:
Email:
HEALTH SAVINGS ACCOUNT
Distribution Request Form
You can complete this form and fax it to (405) 523-5072 or mail it to: American Fidelity Health Services Administration, 2000 N Classen Blvd. 7E
Oklahoma City, OK 73106. A manual distribution fee of $10.00 will be automatically deducted from your health savings account for each distribution
form submitted. To avoid this distribution fee, simply login to your online account at
and request an on-line withdrawal.
A. General Information
Name
Social Security #
Employer Name
Address
(if applicable)
Email address
City, State, Zip
Daytime Phone
Home Phone
B. Distribution Information
Distributions can be made directly from your HSA 24/7 by logging into your account.
Distribution amount
$
Check
Method of distribution
Direct Deposit
(For direct deposit, complete Section C)
Do not send your eligible medical expense receipts with your
distribution request. All receipts should be kept for your tax records.
Eligible Medical Expense
($10 fee)
Yes
Will this distribution close the account?
Reason for distribution
Excess Contribution Removal ($15 fee)
No
($25 closing fee)
Ineligible Medical Expense
($10 fee)
C. Direct Deposit Information (if applicable)
Bank Name
Bank Phone
Bank Routing Number
Checking
Deposit Account
Savings
Bank Account Number
ATTACH COPY OF VOIDED CHECK/SAVINGS WITHDRAWAL FORM HERE
Sample
I certify that I am the proper party to receive payment(s) from the HSA and that all information provided by me is true and accurate. I further certify that no tax
advice has been given to me by American Fidelity Health Services Administration (AFHSA). All decisions regarding this distribution are my own. I expressly
assume the responsibility for any adverse consequences which may arise from this distribution and I agree that AFHSA shall in no way be held responsible.
I hereby authorize (AFHSA) to make deposits to my account. I understand that it will take approximately 7-10 business days from the date that AFHSA
receives this authorization for the direct deposit to occur. I understand that it is my responsibility to notify AFHSA of any changes to my bank account number
and routing number. If I fail to notify AFHSA of any changes, I will be responsible for reimbursing AFHSA for all applicable bank charges.
Signature of Accountholder
Date
FOR OFFICE USE ONLY
RECEIVED BY:
PROCESSED ON:
PROCESSED BY:
M-3146-0412

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