HSA Contribution Form - Contribution and account details - sign and date

Sep 19, 2026

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HSA Contribution Form collects account and identity information needed to submit a contribution to a WealthCare Saver Health Savings Account (HSA). The form directs contributors to send a check payable to WealthCare Saver FBO with the specified amount and the HSA account number. It provides options for standard contributions (current year, prior year, or catch-up) and rollover contributions with transaction codes, plus instructions on handling mistaken distributions and mailing addresses. Section 3 requires the account holder’s legal signature, date, and certification.

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CategoryForms

FormatPDF

Pages1

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Section 1: Account Information

Contribution Type and Year

Section 2: Contribution Information

Section 3: Signature

HSA Contribution Form Please complete this form to make a contribution to your WealthCare Saver* Health Savings Account (HSA) . Enclose a check made payable to WealthCare Saver FBO (Account Holder Name) HSA in the amount specified below and include your HSA account number on your check. NOTE: If you instruct the trustee of your HSA/MSA to transfer funds directly to WealthCare Saver, the transfer is not considered a rollover. Use a WealthCare Saver Transfer of Assets form for this purpose, not this form. Mail completed form to: WealthCare Saver \#010163 BIN 88163 Milwaukee, WI 53288-0163 Overnight completed form to: WealthCare Saver \#010163 4900 W. Brown Deer Road Milwaukee, WI 53223 Questions about this form? Contact the number on the back of your debit card Section 1: Account Information | ACCOUNT NUMBER (12 digits beginning with 601)
LAST NAME FIRST NAME EMPLOYER NAME
EMAIL ADDRESS | | | --- | --- | | | MIDDLE INITIAL
- - | | | SOCIAL SECURITY NUMBER | | | TELEPHONE NUMBER | | STREET ADDRESS | | CITY STATE ZIP CODE | CONTRIBUTION TYPE AND YEAR (CHOOSE ONE)
CONTRIBUTION AMOUNT
RETURN OF MISTAKEN DISTRIBUTION
A return of an HSA distribution taken for an unqualified medical expense.
Prior year contributions may only be made up until the tax deadline of the current year. Undesignated contributions will be applied as a Standard Contribution for the Current Year.

Current Tax Year (Transaction Code 204)
Prior Tax Year
(Transaction Code 205)

STANDARD
A standard contribution would include a current year, prior year or catch-up contribution.
Current Tax Year (Transaction Code 200)
Prior Tax Year (Transaction Code 201)
Catch-up Contribution (Transaction Code 206)
| | --- | |
ROLLOVER
Rollover from another HSA or MSA. I understand that I can roll over amounts from Archer MSAs and other HSAs into an HSA and that I must roll over the amount within 60 days after the date of receipt. I further understand that I can make only one rollover contribution to an HSA/MSA during a one year period and that a rollover contribution isnot included in my income, is not deductible and does not affect my contribution limit.
Rollover Contribution (Transaction Code 207) | Section 2: Contribution Information Section 3: Signature I certify that I am the HSA account holder or an individual authorized to execute this transaction. I have read and understand the terms and conditions regarding this transaction as described in the Custodial Agreement provided when opening this HSA account. I assume full responsibility for this transaction and will not hold WealthCare Saver as Custodian, or its affiliates, liable for any adverse consequences that may result. I have not received tax or legal advice from WealthCare Saver as Custodian, or its affiliates, and, if necessary, will seek the advice of a tax professional or legal counsel to ensure my compliance with related laws. All information provided by me is true and correct and may be relied upon by WealthCare Saver as Custodian. / / LEGAL SIGNATURE OF ACCOUNT HOLDER (FIRST & LAST NAME REQUIRED) DATE 􀀍$OHJHXV 7HFKQRORJLHV􀀏 //&􀀏 G􀀒E􀀒D :HDOWK&DUH 6DYHU􀀏 LV OLFHQVHG ZLWK WKH ,56 DV D 1RQ􀀐%DQN &XVWRGLDQ Rev 􀀓􀀘􀀕􀀓􀀕􀀘

FAQs

What must be included when submitting this HSA contribution form by check?

Include a check payable to WealthCare Saver FBO (account holder name) for the specified amount, and include your HSA account number on the check.

How are standard and rollover contributions different on the form?

Standard contributions can be made for the current year, prior year, or as a catch-up contribution. Rollover contributions come from another HSA or MSA and must be rolled over within 60 days of receipt.

What does Section 3 require from the account holder?

It requires certification that you are the HSA account holder (or authorized individual), your legal signature with first and last name, and the date.

Sep 19, 2026

Upload by Fahsai