[{"data":1,"prerenderedAt":-1},["ShallowReactive",2],{"doc-seo-301267-105":3,"doc-detail-301267-en":84,"detail-sidebar-cat-1-en-105":100},{"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":77,"head_meta":79,"extra_data":81,"updated_unix":83},105,"en","hsa-distribution-of-excess-mistaken-contribution-form-rev-052025","HSA Distribution of Excess Mistaken Contribution Form - Rev 052025","","Distribution of Excess Contribution form for HSA account holders who have exceeded annual contribution limits set by the IRS. The form requests debit of over-contributed funds from the WealthCare Saver HSA and return to the holder via ACH transfer or check, including calculations of excess amount and related earnings. Instructions cover account holder information, excess contribution removal with earnings (including references to IRS guidance), disbursement methods, and required legal signature, certification, and fee acknowledgement for the requested distribution.",{"@graph":14,"@context":76},[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/hsa-distribution-of-excess-mistaken-contribution-form-rev-052025/301267/",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-distribution-of-excess-mistaken-contribution-form-rev-052025/301267.png","ImageObject",442,249,{"name":42,"@type":43},"River Wang","Person",{"url":19,"name":45,"@type":46},"DocShare","Organization","application/pdf","2026-09-24","2026-09-19",true,{"@type":52,"interactionType":53,"userInteractionCount":26},"InteractionCounter",{"@type":54},"ViewAction",{"@type":56,"mainEntity":57},"FAQPage",[58,64,68,72],{"name":59,"@type":60,"acceptedAnswer":61},"What information is required in Section 1 for the account holder?","Question",{"text":62,"@type":63},"You must provide account number, last name, first name, middle initial, social security number, email address, telephone number, and complete street address, city, state, and ZIP code.","Answer",{"name":65,"@type":60,"acceptedAnswer":66},"What does Section 2 require when removing excess contributions?",{"text":67,"@type":63},"Section 2 requires the excess amount being removed and the earnings on that excess, noting that excesses and removals are reported on specific IRS tax forms in the relevant years.",{"name":69,"@type":60,"acceptedAnswer":70},"How will the disbursed funds be returned to the account holder?",{"text":71,"@type":63},"Funds are deposited electronically to the direct deposit bank account on file; if no bank account is on file, a check will be mailed to the address on the account.",{"name":73,"@type":60,"acceptedAnswer":74},"What does the signature section certify and acknowledge?",{"text":75,"@type":63},"The account holder certifies legal authorization to receive payments, that the information is true, acknowledges no tax advice was provided by the custodian, assumes responsibility for the distribution, and confirms understanding of applicable terms and potential fees.","https://schema.org",{"og:url":32,"og:type":78,"og:title":10,"og:site_name":45,"og:description":12},"article",{"robots":80,"canonical":32},"index,follow",{"doc_id":82,"site_id":7},301267,1790234609,{"code":4,"msg":85,"data":86},"success",{"doc_id":82,"user_id":87,"nickname":42,"user_avatar":88,"doc_module":22,"category_id":89,"category_name":29,"doc_title":10,"doc_description":12,"doc_content":90,"file_id":91,"file_url":92,"file_type":93,"file_size":94,"view_count":33,"is_deleted":4,"is_public":22,"is_downloadable":22,"audit_status":22,"page_count":26,"language":95,"language_code":8,"site_id":7,"html_lang":8,"table_of_contents":96,"faqs":97,"seo_title":98,"seo_description":12,"update_tm":99,"read_time":22},1099514067438,"https://ap-avatar.wpscdn.com/avatar/100002539ee87300030?x-image-process=image/resize,m_fixed,w_180,h_180&k=1780474512215547542",17,"Distribution of Excess Contribution Must be filled out by Account Holder  \nThe total annual contribution limits are set each year by the Internal Revenue Service (IRS) .  \nYou can find those [limits online at www.IRS.gov. If you](limits online at www.IRS.gov. If you) have exceeded the contribution limit, please complete this form to request the over contributed funds be debited from your WealthCare Saver* Health Savings Account (HSA) and returned to you via ACH transfer or check. You may wish to review IRS Publication 969 found [at www.irs.gov/pub/irs-pdf/p969.pdf](at www.irs.gov/pub/irs-pdf/p969.pdf).  \nFax completed form to: Mail completed form to: Questions about this form?  \n855.588.1028 WealthCare Saver 888-345-7990 Option 1  \nP.O. Box 162177 Altamonte Springs, FL 32716  \n Section 1: Account Holder Information   \n\n| ACCOUNT NUMBER (12 digits beginning with 601)\u003Cbr>LAST NAME FIRST NAME |  |\n| --- | --- |\n|  | MIDDLE INITIAL |\n| SOCIAL SECURITY NUMBER\u003Cbr>EMAIL ADDRESS |  |\n|  | TELEPHONE NUMBER |\n| STREET ADDRESS |  |\n\nCITY STATE ZIP CODE  \n Section 2: Excess Contribution Information   \nComplete this section with the amount of excess being removed and earnings on that excess.  \nPlease note: Excess contributions are reported via tax form 5498-SA in the year the contribution is made, and removals are reported via tax form 1099-SA in the year the removal is made.  \n$ $  \nEXCESS AMOUNT (TC 155) EARNINGS ON EXCESS (TC 156)*  \nIRS rules require distribution of excess HSA contributions to be accompanied by earnings on the excess contributions. IRS resources Include IRS Notice 2004-50, Q&A 34. Please note we will not attempt to recalculate the earnings for accuracy.  \n1 Complete Next Page   \n Section 3: Disbursement Instructions   \n Deposit funds electronically to the direct deposit bank account on file.  \n*Please note: If no bank account on file, a check will be mailed.  Mail check(s) to the address on my account  \nSection 4: Signature  \nI certify that I am the HSA account holder and legally authorized to receive payment(s) from this HSA and that all information provided by me is true and correct. I further certify that no tax advice has been given to me by WealthCare Saver* as Custodian, or its affiliates. I understand that I may consult a tax professional or legal counsel. All decisions regarding this distribution of my excess contribution are my own. I assume full responsibility for this distribution of my excess contribution and will not hold WealthCare Saver as Custodian, or its affiliates, liable for any adverse consequences that may result.  \nI acknowledge that I have read and understand the terms and conditions applicable to a distribution of my excess contribution as set forth in the Custodial Agreement provided when opening this HSA. I understand that any applicable fees will be deducted from the distribution amount requested. (See HSA Fee Schedule on the Portal) .  \n    /   /   LEGAL SIGNATURE OF ACCOUNT HOLDER (FIRST & LAST NAME REQUIRED) DATE  \n*Alegeus Technologies, LLC, d/b/a WealthCare Saver, is licensed with the IRS as a Non-Bank Custodian  \nRev 052025  \n2","cbCaig0KIkAZ1CQa","https://ap.wps.com/l/cbCaig0KIkAZ1CQa","pdf",185270,"English","# Section 1: Account Holder Information\n# Section 2: Excess Contribution Information\n# Section 3: Disbursement Instructions\n# Section 4: Signature","[{\"question\":\"What information is required in Section 1 for the account holder?\",\"answer\":\"You must provide account number, last name, first name, middle initial, social security number, email address, telephone number, and complete street address, city, state, and ZIP code.\"},{\"question\":\"What does Section 2 require when removing excess contributions?\",\"answer\":\"Section 2 requires the excess amount being removed and the earnings on that excess, noting that excesses and removals are reported on specific IRS tax forms in the relevant years.\"},{\"question\":\"How will the disbursed funds be returned to the account holder?\",\"answer\":\"Funds are deposited electronically to the direct deposit bank account on file; if no bank account is on file, a check will be mailed to the address on the account.\"},{\"question\":\"What does the signature section certify and acknowledge?\",\"answer\":\"The account holder certifies legal authorization to receive payments, that the information is true, acknowledges no tax advice was provided by the custodian, assumes responsibility for the distribution, and confirms understanding of applicable terms and potential fees.\"}]","HSA Distribution of Excess Mistaken Contribution Form - Rev 052025 | PDF",1789780546,{"code":4,"msg":85,"data":101},[102,107,112,117,122,127,130,135,140],{"id":103,"doc_module":22,"doc_module_name":25,"category_name":104,"show_sort_weight":105,"slug":106},11,"Presentations",90,"presentations",{"id":108,"doc_module":22,"doc_module_name":25,"category_name":109,"show_sort_weight":110,"slug":111},12,"Resumes",80,"resumes",{"id":113,"doc_module":22,"doc_module_name":25,"category_name":114,"show_sort_weight":115,"slug":116},14,"Invoices",70,"invoices",{"id":118,"doc_module":22,"doc_module_name":25,"category_name":119,"show_sort_weight":120,"slug":121},15,"Posters",60,"posters",{"id":123,"doc_module":22,"doc_module_name":25,"category_name":124,"show_sort_weight":125,"slug":126},16,"Social Media",50,"social-media",{"id":89,"doc_module":22,"doc_module_name":25,"category_name":29,"show_sort_weight":128,"slug":129},40,"forms",{"id":131,"doc_module":22,"doc_module_name":25,"category_name":132,"show_sort_weight":133,"slug":134},18,"Letters",30,"letters",{"id":136,"doc_module":22,"doc_module_name":25,"category_name":137,"show_sort_weight":138,"slug":139},21,"Paper Templates",5,"papers-templates",{"id":141,"doc_module":22,"doc_module_name":25,"category_name":142,"show_sort_weight":4,"slug":143},158,"General","general-158"]