[{"data":1,"prerenderedAt":-1},["ShallowReactive",2],{"doc-seo-304063-105":3,"detail-sidebar-cat-1-en-105":80,"doc-detail-304063-en":126},{"code":4,"msg":5,"data":6},0,"ok",{"site_id":7,"language":8,"slug":9,"title":10,"keywords":11,"description":12,"schema_data":13,"social_meta":73,"head_meta":75,"extra_data":77,"updated_unix":79},105,"en","health-savings-account-hsa-contribution-form-complete-and-sign","Health Savings Account (HSA) Contribution Form - Complete and Sign","","Health Savings Account (HSA) Contribution Form instructions for completing all required fields and submitting the signed form with the completed check to the address provided. The form collects accountholder details, including personal contact information, account number, and full 9-digit Social Security number, with warnings that missing required data may delay or return contributions. It also requests contribution amount and whether the contribution is for the current or prior year, plus consumer authorization and signatures, and outlines regular and catch-up contribution rules.",{"@graph":14,"@context":72},[15,34,55],{"@type":16,"itemListElement":17},"BreadcrumbList",[18,23,27,31],{"item":19,"name":20,"@type":21,"position":22},"https://docshare.wps.com","Home","ListItem",1,{"item":24,"name":25,"@type":21,"position":26},"https://docshare.wps.com/template/","Template",2,{"item":28,"name":29,"@type":21,"position":30},"https://docshare.wps.com/template/forms/","Forms",3,{"item":32,"name":10,"@type":21,"position":33},"https://docshare.wps.com/template/health-savings-account-hsa-contribution-form-complete-and-sign/304063/",4,{"url":32,"name":10,"@type":35,"image":36,"author":41,"headline":10,"publisher":44,"fileFormat":47,"inLanguage":8,"description":12,"dateModified":48,"datePublished":49,"encodingFormat":47,"isAccessibleForFree":50,"interactionStatistic":51},"DigitalDocument",{"url":37,"@type":38,"width":39,"height":40},"https://docshare.wps.com/thumbnails/health-savings-account-hsa-contribution-form-complete-and-sign/304063.png","ImageObject",442,249,{"name":42,"@type":43},"Sarah ","Person",{"url":19,"name":45,"@type":46},"DocShare","Organization","application/pdf","2026-09-24","2026-09-19",true,{"@type":52,"interactionType":53,"userInteractionCount":22},"InteractionCounter",{"@type":54},"ViewAction",{"@type":56,"mainEntity":57},"FAQPage",[58,64,68],{"name":59,"@type":60,"acceptedAnswer":61},"Where should the completed and signed HSA contribution form be sent?","Question",{"text":62,"@type":63},"Send the signed form and the completed check to 909 N 8th Street, Suite 200, Sheboygan, WI 53081-4056.","Answer",{"name":65,"@type":60,"acceptedAnswer":66},"What information is required from the accountholder?",{"text":67,"@type":63},"The form requires accountholder details including first, middle initial, last name, street address, city, state, ZIP code, daytime phone number, email address, and either the full account number or the full 9-digit Social Security number.",{"name":69,"@type":60,"acceptedAnswer":70},"What are the rules for current year vs. prior year contributions?",{"text":71,"@type":63},"If a year is not specified, the contribution is posted for the year it is received. Prior-year contributions must be received by the tax filing deadline.","https://schema.org",{"og:url":32,"og:type":74,"og:title":10,"og:site_name":45,"og:description":12},"article",{"robots":76,"canonical":32},"index,follow",{"doc_id":78,"site_id":7},304063,1790211053,{"code":4,"msg":81,"data":82},"success",[83,88,93,98,103,108,112,117,122],{"id":84,"doc_module":22,"doc_module_name":25,"category_name":85,"show_sort_weight":86,"slug":87},11,"Presentations",90,"presentations",{"id":89,"doc_module":22,"doc_module_name":25,"category_name":90,"show_sort_weight":91,"slug":92},12,"Resumes",80,"resumes",{"id":94,"doc_module":22,"doc_module_name":25,"category_name":95,"show_sort_weight":96,"slug":97},14,"Invoices",70,"invoices",{"id":99,"doc_module":22,"doc_module_name":25,"category_name":100,"show_sort_weight":101,"slug":102},15,"Posters",60,"posters",{"id":104,"doc_module":22,"doc_module_name":25,"category_name":105,"show_sort_weight":106,"slug":107},16,"Social Media",50,"social-media",{"id":109,"doc_module":22,"doc_module_name":25,"category_name":29,"show_sort_weight":110,"slug":111},17,40,"forms",{"id":113,"doc_module":22,"doc_module_name":25,"category_name":114,"show_sort_weight":115,"slug":116},18,"Letters",30,"letters",{"id":118,"doc_module":22,"doc_module_name":25,"category_name":119,"show_sort_weight":120,"slug":121},21,"Paper Templates",5,"papers-templates",{"id":123,"doc_module":22,"doc_module_name":25,"category_name":124,"show_sort_weight":4,"slug":125},158,"General","general-158",{"code":4,"msg":81,"data":127},{"doc_id":78,"user_id":128,"nickname":42,"user_avatar":129,"doc_module":22,"category_id":109,"category_name":29,"doc_title":10,"doc_description":12,"doc_content":130,"file_id":131,"file_url":132,"file_type":133,"file_size":134,"view_count":30,"is_deleted":4,"is_public":22,"is_downloadable":22,"audit_status":22,"page_count":22,"language":135,"language_code":8,"site_id":7,"html_lang":8,"table_of_contents":136,"faqs":137,"seo_title":138,"seo_description":12,"update_tm":139,"read_time":4},962085320529,"https://ap-avatar.wpscdn.com/davatar_9964176cb1d06d4a9deccf72a44ae3dc","Health Savings Account (HSA) Contribution Form  \nInstructions: Complete all the fields below and return the signed form and completed check to: 909 N 8th Street, Suite 200, Sheboygan, WI 53081-4056. For assistance, please call the number on the back of your debit card, or 800-357-6246 if you don’t have it. You can monitor your transactions [in your online account at](in your online account at hsabank.com)[ hsabank.com](in your online account at hsabank.com).  \nAccountholder Information  \n\n| First name: | Middle initial: |  | Last name: |\n| --- | --- | --- | --- |\n| Street address: |  |  |  |\n| City: | State: |  | ZIP code: |\n| Daytime phone number: |  | Email address: |  |\n| Account number (8 or 12 digits from your welcome kit or your online account. The account number is located in your online account under My Profile in the settings. The account number is NOT the same as your debit card number.): |  |  |  |\n| Full 9-digit Social Security number: |  |  |  |\n| Note: Full account number OR full SSN required. Failure to provide the required information may result in a delay or return of your contribution. |  |  |  |\n\nContribution Information  \n\n| Contribution amount: $ |\n| --- |\n| Contribution for: 􀀜 Current year 􀀜 Prior year\u003Cbr>Note: Ifa year is not specified, your contribution will be posted for the year in which it is received. Prior-year contributions must be received by the tax filing deadline. HSA Bank does not provide tax or legal advice. Please seek the advice of a tax or legal professional to ensure compliance with health savings account regulations. |\n\nConsumer Authorization  \n\n| I certify that I am the HSA member 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 HSA Bank liable for any adverse consequences that may result. I have not received tax or legal advice from HSA Bank. If necessary, I 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 HSA Bank. |  |\n| --- | --- |\n| Accountholder signature: | Date: |\n\nRules and Conditions Applicable to Contributions  \nRegular contribution: Annual maximum contribution limits can vary from year to year. For current contribution maximums, [visit](visit hsabank.com/irs-guidelines)[ hsabank.com/irs-guidelines](visit hsabank.com/irs-guidelines).  \nCatch-up contribution: If you are 55 years of age or older during the calendar year, you may make one additional “catch up”contribution of up to $1,000 .  \n© 2023-2026 HSA Bank. HSA Bank® is a division of Santander Bank, N.A. , Member FDIC.  \nPlan Administrative Services and Benefit Services are administered by Webster Servicing LLC. Health_Savings_Account_Contribution_Form_060826","cbCaic9Qkh2K39Vq","https://ap.wps.com/l/cbCaic9Qkh2K39Vq","pdf",350395,"English","# Accountholder Information\n# Contribution Information\n# Consumer Authorization\n# Rules and Conditions Applicable to Contributions","[{\"question\":\"Where should the completed and signed HSA contribution form be sent?\",\"answer\":\"Send the signed form and the completed check to 909 N 8th Street, Suite 200, Sheboygan, WI 53081-4056.\"},{\"question\":\"What information is required from the accountholder?\",\"answer\":\"The form requires accountholder details including first, middle initial, last name, street address, city, state, ZIP code, daytime phone number, email address, and either the full account number or the full 9-digit Social Security number.\"},{\"question\":\"What are the rules for current year vs. prior year contributions?\",\"answer\":\"If a year is not specified, the contribution is posted for the year it is received. Prior-year contributions must be received by the tax filing deadline.\"}]","Health Savings Account (HSA) Contribution Form - Complete and Sign | PDF",1789809677]