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The form collects account holder and employer details, distribution choices (close or keep open), requested amounts, and distribution types such as transfer, excess contribution removal, rollover, normal distribution, divorce, disability, and prohibited or mistaken contributions. 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If the distribution is because of the death of the accountholder, please complete the Health Savings Account (HSA) Death Distribution Request Form. Please submit completed form via email, fax or mail.  \n*=Required Fields  \nStep 1: Accountholder Information  \n*Employer Name (Do not abbreviate)  \n*Participant Name (First, MI, Last)  \nEmployee ID Number  \n- -  \n*Social Security Number  \n*Date of Birth (mm/dd/yyyy)  \nEnsure you’re enrolled with your new custodian prior to submitting this form to Aptia. If your funds are returned to Aptia, your HSA will be reopened with Aptia and the funds will be re-contributed into the account.  \nStep 2a: Distribution Information  \nIndicate the balance to distribute and select whether you’d like to close your HSA or leave it open. Please note that, upon closing the account, you may be charged a $15 account closure fee (regardless of distribution type). Once the account is closed, contributions can no longer be made.  \nDistribute full account balance using the method selected below. Close HSA. Note: All Health Savings  \nBrokerage Account (HSBA) investments must be liquidated before we can close your account.  \nDistribute full account balance using the method selected below. Keep HSA open.  \nDistribute designated amount using the method selected below. Keep HSA open. *Requested Amount: $  \nStep 2b: Distribution Information  \nCheck the distribution type, and complete the instructions on the right for an Excess Contribution Removal or Transfer.  \nTransfer (distributed to new custodian—complete first two boxes on the right;  \nplease verify transfer address with your new custodian)  \nExcess Contribution Removal (complete third box on the right) Rollover (funds distributed to account owner)  \nNormal Distribution  \nDivorce (copy of the Divorce Decree is required. Complete first two boxes on the right.)  \nDisability  \nProhibited Transaction  \nMistaken Contribution  \nStep 3: Authorized Signatures  \n\n| Note: Complete these boxes only if you checked “Transfer” or “Divorce” as your distribution type. |  |\n| --- | --- |\n| Provide your new custodian’s name and address below (must be enrolled with new custodian; see Page 2 for details).\u003Cbr>Provide your account number with your new custodian: | Note: Leaving the Account Number field blank may result in the check being returned. |\n\nNote: Complete these boxes only if you checked “Excess Contribution Removal” as your distribution type.  \nProvide the date the excess contribution occurred (mm/dd/ yyyy): (Note: If there are multiple excess contributions, provide the date of the first one.)  \nI certify that I am the proper party to receive payment(s) from this HSA and that all information provided by me is true and accurate. I further certify that no tax advice has been given to me by Aptia. All decisions regarding this distribution are my own. I expressly assume the responsibility for any adverse consequences that may arise from this distribution and I agree that Aptia shall in no way be held responsible. I acknowledge that as part of closing my HSA, Aptia will initiate the liquidation of my investments, if applicable, and wait up to 10 days to allow for any outstanding debit card transactions to settle before mailing the final distribution check. I acknowledge that I have read and understood the Rules and Conditions applicable to a distribution on page two. I understand that any applicable fees will be deducted from the distribution amount requested. I understand that my signature is required to certify that the information I have provided is true and correct and that I am aware of all the circumstances affecting this HSA withdrawal.  \n*Accountholder Signature *Date  \n*B107* *K417*  \nHSA Distribution Request","cbCailVqOfbnVTYD","https://ap.wps.com/l/cbCailVqOfbnVTYD","pdf",106251,"English","# Accountholder Information\n# Distribution Information\n## Distribution Information (types and instructions)\n# Authorized Signatures\n# Rules and Conditions Applicable to Withdrawal\n## Distribution reason details (transfer, excess contribution removal, rollover, normal)","[{\"question\":\"What is this HSA form used for?\",\"answer\":\"It is used to request an HSA distribution of funds or to close an HSA account. If the distribution is due to the account holder’s death, a different death distribution request form is required.\"},{\"question\":\"What happens when you close your HSA account?\",\"answer\":\"A $15 account closure fee may be charged regardless of distribution type. Once closed, contributions can no longer be made, and investments may be liquidated before the final distribution check is mailed.\"},{\"question\":\"Which distribution reasons are available on the form?\",\"answer\":\"The form supports transfer to a new custodian, excess contribution removal, rollover, normal distribution for eligible expenses, and additional categories such as divorce, disability, prohibited transaction, and mistaken contribution.\"}]","HSA Distribution Request/Account Closure Form | PDF",1789806170]