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The document specifies mailing details for a check payable to TASC (TPA), provides contact options using a TASC ID, and explains rollover rules such as 60-day deposit timing and limits on the number of rollovers. It also covers investment treatment for amounts above the cash minimum and requires signature authorization.",{"@graph":69,"@context":123},[70,84,106],{"@type":71,"itemListElement":72},"BreadcrumbList",[73,77,79,82],{"item":74,"name":75,"@type":76,"position":8},"https://docshare.wps.com","Home","ListItem",{"item":78,"name":9,"@type":76,"position":14},"https://docshare.wps.com/document/",{"item":80,"name":35,"@type":76,"position":81},"https://docshare.wps.com/document/healthcare/",3,{"item":83,"name":65,"@type":76,"position":19},"https://docshare.wps.com/document/tasc-hsa-contribution-request-form-instructions/265968/",{"url":83,"name":65,"@type":85,"image":86,"author":91,"headline":65,"publisher":94,"fileFormat":97,"inLanguage":63,"description":67,"dateModified":98,"datePublished":99,"encodingFormat":97,"isAccessibleForFree":100,"interactionStatistic":101},"DigitalDocument",{"url":87,"@type":88,"width":89,"height":90},"https://docshare.wps.com/thumbnails/tasc-hsa-contribution-request-form-instructions/265968.png","ImageObject",300,407,{"name":92,"@type":93},"Aria","Person",{"url":74,"name":95,"@type":96},"DocShare","Organization","application/pdf","2026-10-22","2026-09-14",true,{"@type":102,"interactionType":103,"userInteractionCount":105},"InteractionCounter",{"@type":104},"ViewAction",18,{"@type":107,"mainEntity":108},"FAQPage",[109,115,119],{"name":110,"@type":111,"acceptedAnswer":112},"What information is required to complete the TASC HSA contribution request?","Question",{"text":113,"@type":114},"The form requires accountholder details such as name, email, phone, address, and identification numbers, plus contribution amount and the contribution tax year. It also requires selecting a contribution type and providing signature authorization.","Answer",{"name":116,"@type":111,"acceptedAnswer":117},"How do rollover contributions work under the rollover rules?",{"text":118,"@type":114},"Rollover contributions move money or property between an HSA or MSA. Funds must be deposited into the receiving HSA within 60 days, and only one rollover contribution per HSA is allowed in a 12-month period.",{"name":120,"@type":111,"acceptedAnswer":121},"What should be done for mistaken distribution contributions?",{"text":122,"@type":114},"Payment for a mistaken distribution must occur before December 31 of the year in which the mistaken distribution occurred. Contributions received after December 31 are applied to the contribution maximum for the following year.","https://schema.org",{"og:url":83,"og:type":125,"og:title":65,"og:site_name":95,"og:description":67},"article",{"robots":127,"canonical":83},"index,follow",{"doc_id":129,"site_id":62},265968,1789402846,{"code":4,"msg":5,"data":132},{"doc_id":129,"user_id":133,"nickname":92,"user_avatar":134,"doc_module":4,"category_id":34,"category_name":35,"doc_title":65,"doc_description":67,"doc_content":135,"file_id":136,"file_url":137,"file_type":138,"file_size":139,"view_count":105,"is_deleted":4,"is_public":8,"is_downloadable":8,"audit_status":8,"page_count":8,"language":140,"language_code":63,"site_id":62,"html_lang":63,"table_of_contents":141,"faqs":142,"seo_title":143,"seo_description":67,"update_tm":130,"read_time":81},2336464648322,"https://ap-avatar.wpscdn.com/avatar/2200025388227c56fec?_k=1778556882303663488","| INSTRUCTIONS |\n| --- |\n| 1. Complete this form to make a normal, mistaken distribution, rollover or transfer contribution to your TASC HSA.\u003Cbr>2. Enclose a check made payable to TASC (TPA) and mail with completed form to: TASC, PO Box 7308 Madison, Wisconsin 53704-7308\u003Cbr>3. If you have any questions about contributing to your HSA, call TASC at 800-422-4661 with your TASC ID \\# available. |\n| ACCOUNTHOLDER INFORMATION |\n\n\n| TASC ID \\#: |  |  |  |  |  |  |  |  |  |  |\n| --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- |\n| First Name: |  |  | MI: |  |  | Last Name: |  |  |  |  |\n| Email Address: |  |  |  | Social Security Number: |  |  |  |  |  |  |\n| Primary Phone \\#: |  |  |  | Mobile Phone \\#: |  |  |  |  |  |  |\n| Primary Address: | Street: |  |  |  |  |  |  |  | Apt: |  |\n|  | City: |  |  |  |  |  |  |  |  |  |\n|  | State: |  |  |  |  | Zip/Postal Code: |  |  | +4 |  |\n\nCONTRIBUTION INFORMATION  \nNote: Contributions over the cash minimum qualify to be invested and will be placed by default into an interest-bearing account. You may change your current and future investment allocations anytime online (log in at [tasconline.com](tasconline.com)) .  \n\n| Contribution Amount $ |  |  |  | Contribution Tax Year: |  |\n| --- | --- | --- | --- | --- | --- |\n| Contribution Type:\u003Cbr>(select one) | ☐ Normal: A normal contribution would include a regular, catch-up, or post-tax contribution.☐ Mistaken Distribution: Payment for a mistaken distribution must occur before December\u003Cbr>31 of the year in which the mistaken distribution occurred. Contributions received after\u003Cbr>December 31 will be applied to the contribution maximum for the following year.☐ Rollover from (select one): ☐ HSA ☐ MSA (please include a check) |  |  |  |  |\n|  | Rules and Conditions Regarding Rollovers: A rollover is a way to move money or property from one HSA or Medical Savings Account (MSA) to another HSA. The Internal Revenue Code limits the number of rollovers that may be taken, how quickly rollovers must be completed and how the trustee or custodian must report the transaction.\u003Cbr>Timeliness: The funds you receive from the distributing HSA or MSA must be deposited into another HSA within 60 days of receipt of funds.\u003Cbr>12 Month Restriction: You can only make one rollover contribution per HSA to another HSA in a 12-month period. IRA restriction is once per lifetime. |  |  |  |  |\n| Transfer from (select one): |  | ☐ HSA ☐ MSA ☐ IRA | ☐ A check is enclosed from the previous trustee or custodian |  |  |\n\nSIGNATURE/AUTHORIZATION  \nI 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 and have met the requirements for making this transaction. I assume full responsibility for this transaction and will not hold TASC or State Bank of Cross Plains (SBCP) liable for any adverse consequences that may result. I have not received tax or legal advice from TASC or State Bank of Cross Plains 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 TASC and State Bank of Cross Plains. If I have chosen rollover or transfer as the contribution type, I make an irrevocable election to treat this transaction as such.  \nHSA Accountholder Signature Date","cbCaighqKie5spSG","https://ap.wps.com/l/cbCaighqKie5spSG","pdf",256251,"English","# Instructions\n## Accountholder information\n## Contribution information\n## Signature/authorization","[{\"question\":\"What information is required to complete the TASC HSA contribution request?\",\"answer\":\"The form requires accountholder details such as name, email, phone, address, and identification numbers, plus contribution amount and the contribution tax year. It also requires selecting a contribution type and providing signature authorization.\"},{\"question\":\"How do rollover contributions work under the rollover rules?\",\"answer\":\"Rollover contributions move money or property between an HSA or MSA. Funds must be deposited into the receiving HSA within 60 days, and only one rollover contribution per HSA is allowed in a 12-month period.\"},{\"question\":\"What should be done for mistaken distribution contributions?\",\"answer\":\"Payment for a mistaken distribution must occur before December 31 of the year in which the mistaken distribution occurred. Contributions received after December 31 are applied to the contribution maximum for the following year.\"}]","TASC HSA Contribution Request Form - Instructions | PDF"]