Account Close Request To Disburse Funds

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REQUEST FOR COPY OF HSA TAX FORM
Account Holder Instructions
®
To request copies of HSA tax forms for your BenefitWallet
Health Savings Account (HSA) complete this form and
send the ORIGINAL form to The Bank of New York Mellon (BNY Mellon) at the address below. BNY Mellon will
charge your account a fee of $5, or as stated on your rate and fee schedule, per tax form in accordance with the
Health Savings Account Fee and Rate schedule. Please allow 20 business days to process your request.
Send this completed and signed form (not a copy) to BNY Mellon at:
Mail:
Courier/Overnight:
BenefitWallet
BenefitWallet
th
P.O. Box 1584
500 Plaza Drive 8
Floor
Secaucus, NJ 07094-1584
Secaucus, NJ 07094
* Note: Beginning with 2010, tax forms are available online at
RTF201306

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