[{"data":1,"prerenderedAt":-1},["ShallowReactive",2],{"doc-seo-303851-105":3,"detail-sidebar-cat-1-en-105":81,"doc-detail-303851-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":74,"head_meta":76,"extra_data":78,"updated_unix":80},105,"en","hsa-contribution-form-deposit-money-into-your-hsa-2025","HSA Contribution Form - Deposit Money Into Your HSA - 2025","","HSA contribution form for depositing money into a Health Savings Account, capturing required consumer information and signature certification. The form explains how to complete Part I and Part II, select a contribution type (Normal, Catch-Up for age 55+, Rollover, or Mistaken Distribution), and provide amount and tax year. It details IRS-related rules, including prior-year contributions by the normal tax-filing deadline and rollover eligibility and timing. Submission instructions include email, mail, and fax details.",{"@graph":14,"@context":73},[15,34,56],{"@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/hsa-contribution-form-deposit-money-into-your-hsa-2025/303851/",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/hsa-contribution-form-deposit-money-into-your-hsa-2025/303851.png","ImageObject",442,249,{"name":42,"@type":43},"Fez","Person",{"url":19,"name":45,"@type":46},"DocShare","Organization","application/pdf","2026-10-03","2026-09-19",true,{"@type":52,"interactionType":53,"userInteractionCount":55},"InteractionCounter",{"@type":54},"ViewAction",5,{"@type":57,"mainEntity":58},"FAQPage",[59,65,69],{"name":60,"@type":61,"acceptedAnswer":62},"What are the steps to submit an HSA contribution form?","Question",{"text":63,"@type":64},"Complete all sections, then email, mail, or fax the completed form to The Harrison Group, Inc. using the provided contact details.","Answer",{"name":66,"@type":61,"acceptedAnswer":67},"Which contribution types can be selected on the form?",{"text":68,"@type":64},"Normal, Catch-Up (age 55+), Rollover, and Mistaken Distribution are listed for selection. Each type has specific rules described in the form.",{"name":70,"@type":61,"acceptedAnswer":71},"Are there IRS timing rules for contributing to a previous tax year or making rollovers?",{"text":72,"@type":64},"Contributions for the previous tax year must be received by the normal tax-filing deadline (typically April 15, excluding extensions). For rollovers, funds must be deposited into another HSA within 60 days, and only one rollover contribution may be made to an HSA during a one-year period.","https://schema.org",{"og:url":32,"og:type":75,"og:title":10,"og:site_name":45,"og:description":12},"article",{"robots":77,"canonical":32},"index,follow",{"doc_id":79,"site_id":7},303851,1790434167,{"code":4,"msg":82,"data":83},"success",[84,89,94,99,104,109,113,118,122],{"id":85,"doc_module":22,"doc_module_name":25,"category_name":86,"show_sort_weight":87,"slug":88},11,"Presentations",90,"presentations",{"id":90,"doc_module":22,"doc_module_name":25,"category_name":91,"show_sort_weight":92,"slug":93},12,"Resumes",80,"resumes",{"id":95,"doc_module":22,"doc_module_name":25,"category_name":96,"show_sort_weight":97,"slug":98},14,"Invoices",70,"invoices",{"id":100,"doc_module":22,"doc_module_name":25,"category_name":101,"show_sort_weight":102,"slug":103},15,"Posters",60,"posters",{"id":105,"doc_module":22,"doc_module_name":25,"category_name":106,"show_sort_weight":107,"slug":108},16,"Social Media",50,"social-media",{"id":110,"doc_module":22,"doc_module_name":25,"category_name":29,"show_sort_weight":111,"slug":112},17,40,"forms",{"id":114,"doc_module":22,"doc_module_name":25,"category_name":115,"show_sort_weight":116,"slug":117},18,"Letters",30,"letters",{"id":119,"doc_module":22,"doc_module_name":25,"category_name":120,"show_sort_weight":55,"slug":121},21,"Paper Templates","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":82,"data":127},{"doc_id":79,"user_id":128,"nickname":42,"user_avatar":129,"doc_module":22,"category_id":110,"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":55,"is_deleted":4,"is_public":22,"is_downloadable":22,"audit_status":22,"page_count":26,"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":22},2336478940794,"https://ap-avatar.wpscdn.com/davatar_9964176cb1d06d4a9deccf72a44ae3dc","Use this form to make a contribution (deposit money) into your HSA. If you have any questions about HSAs or completing this form, please contact us at (855) 222-5727.  \nProcess:  \n1. Complete all sections of this form.  \n2. Email, mail or fax completed form to:  \nEmail: [service@theharrisongrouponline.com](service@theharrisongrouponline.com)  \nAddress: The Harrison Group, Inc., 3 Raymond Drive, Havertown PA 19083  \nFax: (610) 853-9079  \n\n| Part I Consumer Information |  |  |  |  |\n| --- | --- | --- | --- | --- |\n|  |  |  |  |  |\n| *Accountholder Name (First, MI, Last) |  | *Employer Name (If sponsored by an employer plan) |  |  |\n| *Birth Date (MM/DD/YYYY) | *Social Security Number |  | *Day Telephone |  |\n| *Address |  |  |  |  |\n| *City |  | *State |  | *Zip |\n| *Email Address |  |  |  |  |\n\n*Required Fields  \n\n| Part II Contribution Information-􀃆 Please make check payable to: The Harrison Group, Inc.\u003Cbr>Note: The IRS allows HSA account holders to make contributions for the previous tax year as long as it is received by your normal tax-filing deadline (not including extensions), which is typically April 15th of the current year. |  |  |  |  |  |\n| --- | --- | --- | --- | --- | --- |\n| *Select the Type of Contribution (see second page for descriptions) |  |  |  | *Amount\u003Cbr>$ | *For Tax Year |\n|  Normal |  Catch-Up (age 55+) |  Rollover |  Mistaken Distribution |  |  |\n\n\n| Signature |  |\n| --- | --- |\n|  |  |\n| I certify that I am the HSA account holder or another 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 The Harrison Group, Inc. for any adverse consequences that may result. I have not received tax or legal advice from The Harrison Group, Inc. 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 The Harrison Group, Inc. If I have chosen rollover as the contribution type, I make an irrevocable election to treat this transaction as such. I acknowledge that this form may be electronically signed, and I agree that the electronic signature(s) appearing on this document are the same as handwritten signatures for the purpose of validity, enforceability, and admissibility. |  |\n| *Accountholder Signature | *Date |\n\nRules and Conditions Applicable to Contributions  \n\n| General Information | Any contributions received will be deposited in your HSA cash account. If you have enabled investments and have automatic transfers enabled, any funds above the minimum threshold will automatically be swept into an interest-bearing account once the amount above the threshold reaches $100. You can set investment allocations for the mutual fund investments through your account login.\u003Cbr>The IRS allows HSA accountholders to make contributions for the previous tax year through your normal taxfiling deadline (not including extensions), which is typically April 15th of the current year. |\n| --- | --- |\n| Contribution Type | Normal\u003Cbr>See IRS publication 969 available at [http://www.irs.gov/pub/irs-pdf/p969.pdf](http://www.irs.gov/pub/irs-pdf/p969.pdf) for annual contribution limits.\u003Cbr>Catch-Up\u003Cbr>If you are 55 years of age or older during the calendar year, you may make an additional “catch up” contribution of up to $1000.\u003Cbr>Transfer\u003Cbr>Use the Health Savings Account Transfer Form to complete that type of transaction.\u003Cbr>Rollover\u003Cbr>A rollover is a way to move funds from one HSA to another HSA. By properly completing this form , you are certifying to the Custodian that you have satisfied the rules and conditions applicable to your rollover and that you are making an irrevocable election to treat the transaction as a rollover. The rollover only includes funds distributed from either an HSA, Archer Medi","cbCaiteGbsoyM5TU","https://ap.wps.com/l/cbCaiteGbsoyM5TU","pdf",274412,"English","# Instructions and Submission\n## Steps to Complete the Form\n## Where to Send Completed Form\n# Part I: Consumer Information\n## Required Account Holder Details\n# Part II: Contribution Information\n## Contribution Type Selection\n## Amount and Tax Year\n# Rules and Conditions Applicable to Contributions\n## Deposit and Investment Sweep Rules\n## Prior-Year Contribution Deadline\n## Contribution Type Details (Normal, Catch-Up, Rollover, Mistaken Distribution)\n# Signatures and Certification","[{\"question\":\"What are the steps to submit an HSA contribution form?\",\"answer\":\"Complete all sections, then email, mail, or fax the completed form to The Harrison Group, Inc. using the provided contact details.\"},{\"question\":\"Which contribution types can be selected on the form?\",\"answer\":\"Normal, Catch-Up (age 55+), Rollover, and Mistaken Distribution are listed for selection. Each type has specific rules described in the form.\"},{\"question\":\"Are there IRS timing rules for contributing to a previous tax year or making rollovers?\",\"answer\":\"Contributions for the previous tax year must be received by the normal tax-filing deadline (typically April 15, excluding extensions). For rollovers, funds must be deposited into another HSA within 60 days, and only one rollover contribution may be made to an HSA during a one-year period.\"}]","HSA Contribution Form - Deposit Money Into Your HSA - 2025 | PDF",1789807697]