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It explains who must contact Fidelity first for nonresident alien tax considerations, and provides guidance on whether to file IRS Form 5329. The form details required corrections before the tax-filing deadline, earnings or loss calculation requirements, account owner information, excess contribution dates and amounts, distribution options A/B/C, payment method selection, and signature responsibilities.",{"@graph":63,"@context":118},[64,80,101],{"@type":65,"itemListElement":66},"BreadcrumbList",[67,71,74,77],{"item":68,"name":69,"@type":70,"position":9},"https://docshare.wps.com","Home","ListItem",{"item":72,"name":10,"@type":70,"position":73},"https://docshare.wps.com/template/",2,{"item":75,"name":36,"@type":70,"position":76},"https://docshare.wps.com/template/forms/",3,{"item":78,"name":59,"@type":70,"position":79},"https://docshare.wps.com/template/return-of-excess-contributionfidelity-hsa/304128/",4,{"url":78,"name":59,"@type":81,"image":82,"author":87,"headline":59,"publisher":90,"fileFormat":93,"inLanguage":57,"description":61,"dateModified":94,"datePublished":95,"encodingFormat":93,"isAccessibleForFree":96,"interactionStatistic":97},"DigitalDocument",{"url":83,"@type":84,"width":85,"height":86},"https://docshare.wps.com/thumbnails/return-of-excess-contributionfidelity-hsa/304128.png","ImageObject",442,249,{"name":88,"@type":89},"Xiajie","Person",{"url":68,"name":91,"@type":92},"DocShare","Organization","application/pdf","2026-09-25","2026-09-19",true,{"@type":98,"interactionType":99,"userInteractionCount":76},"InteractionCounter",{"@type":100},"ViewAction",{"@type":102,"mainEntity":103},"FAQPage",[104,110,114],{"name":105,"@type":106,"acceptedAnswer":107},"What is this form used for?","Question",{"text":108,"@type":109},"It is used to request a return of an excess contribution made to a Fidelity HSA.","Answer",{"name":111,"@type":106,"acceptedAnswer":112},"What deadline must you meet to use the form?",{"text":113,"@type":109},"You must be correcting the excess contribution before your tax-filing deadline, including any extensions, for the year the excess contribution was made.",{"name":115,"@type":106,"acceptedAnswer":116},"How are distribution options selected?",{"text":117,"@type":109},"Choose option A, B, or C for how the excess amount is disbursed; if no option is selected, option C is used by default.","https://schema.org",{"og:url":78,"og:type":120,"og:title":59,"og:site_name":91,"og:description":61},"article",{"robots":122,"canonical":78},"index,follow",{"doc_id":124,"site_id":56},304128,1790180425,{"code":4,"msg":5,"data":127},{"doc_id":124,"user_id":128,"nickname":88,"user_avatar":129,"doc_module":9,"category_id":35,"category_name":36,"doc_title":59,"doc_description":61,"doc_content":130,"file_id":131,"file_url":132,"file_type":133,"file_size":134,"view_count":76,"is_deleted":4,"is_public":9,"is_downloadable":9,"audit_status":9,"page_count":73,"language":135,"language_code":57,"site_id":56,"html_lang":57,"table_of_contents":136,"faqs":137,"seo_title":138,"seo_description":61,"update_tm":139,"read_time":9},8814010472675,"https://avatar.qwps.com/avatar/WGlhamll","| Print | Reset | Save |\n| --- | --- | --- |\n\nQuestions? Go to [Fidelity.com](Fidelity.com) or call 800-544-3716.  \nReturn of Excess Contribution—Fidelity HSA®  \nUse this form to request a return of an excess contribution made to your Fidelity HSA®. If you are a nonresident alien, please contact Fidelity prior to completing this form, as you may be subject to additional tax-withholding requirements. Type on screen or fill in using CAPITAL letters and black ink. If you need more room for information, make a copy of the relevant page.  \nHelpful to Know  \n• You may be required to file Internal Revenue Service (IRS) Form 5329 to report any additional tax you may owe due to an excess HSA contribution. You are encouraged to consult a tax advisor concerning the correction of excess HSA contributions and your personal situation before completing this form.  \n• When correcting an excess contribution before your tax-filing deadline, including extensions, the IRS requires  \na calculation to determine the earnings or loss on the excess HSA contribution. The earnings or loss amount is factored into the amount of your return of excess distribution. Fidelity will automatically calculate the amount of earnings or loss based on IRS Notice 2000-39 and IRS Final Regulation 1.408-11. If you wish to calculate the earnings or loss instead of Fidelity, please include a signed letter of instruction with this form.  \n1. Account Owner  \n\n|  | Name |  | Fidelity Account Number |\n| --- | --- | --- | --- |\n|  |  |  |  |\n|  | \u003Cbr>Social Security or Taxpayer ID Number |  |  |\n| 2. Excess Contribution Description |  |  |  |\n\nIn order to use this form, you must be correcting this excess contribution before your tax-filing deadline (including any extensions) of the year for which the excess contribution was made.  \nIf you have multiple excess contributions, provide the date of the first excess contribution.  \nDo NOT include any earnings or loss on the excess contribution.  \nTax year for which the excess contribution was made  \n\n| Tax Year YYYY |\n| --- |\n|  |\n\n Date of the deposit  \n\n| Date MM DD YYYY |\n| --- |\n|  |\n\nAmount of excess contribution  \n\n| Dollar Amount |\n| --- |\n|  |\n\nThe excess contribution plus any earnings or loss, if applicable, will be removed from the core position. If there is insufficient cash in the core position, you will need to place a liquidating trade into your core position before the excess contribution can be removed. Trade online at [Fidelity.com](Fidelity.com) or call a representative at 800-544-3716. Allow at least three business days for trade settlement. The distribution of the excess contribution and any attributable earnings may be taxable in the year received. You will receive a Form 1099-SA for the full amount of the excess plus any attributable earnings.  \nDistribution Instructions  \nChoose A, B, or C for how you would like to have the excess amount disbursed. If no option is selected, we will default to option C.  \n A. Redeposit the full amount of the excess contribution made in a prior year plus earnings back into this HSA asa contribution for the current year.  \n B. Redeposit this prior year excess contribution amount back into this HSA as a contribution for the current year and return the balance to me as indicated in Section 3.  \n\n| Dollar Amount |\n| --- |\n|  |\n\n C. Distribute the full amount of the excess contribution plus any earnings to me as indicated in Section 3.  \nForm continues on next page.   \n1.833738.109  \nPage 1  \nof 2  \n031290201  \n3. Method of Payment  \nIndicate how you wish to receive your distribution payment, if applicable, by selecting one of the options below. If no option is selected, a check will be sent to your address of record.  \nCheck one and provide all required information.  \nProvide bank information ONLY if there are  \nmultiple EFT instructions on the account identified in Section 1.  \n Distribute to a Fidelity nonretirement account: Requires Medallion signature guarantee if going to an ac","cbCaieYbp70p2rnF","https://ap.wps.com/l/cbCaieYbp70p2rnF","pdf",1677445,"English","# Account Owner\n# Excess Contribution Description\n# Tax Year and Deposit Details\n# Distribution Instructions\n# Method of Payment\n# Signature and Date","[{\"question\":\"What is this form used for?\",\"answer\":\"It is used to request a return of an excess contribution made to a Fidelity HSA.\"},{\"question\":\"What deadline must you meet to use the form?\",\"answer\":\"You must be correcting the excess contribution before your tax-filing deadline, including any extensions, for the year the excess contribution was made.\"},{\"question\":\"How are distribution options selected?\",\"answer\":\"Choose option A, B, or C for how the excess amount is disbursed; if no option is selected, option C is used by default.\"}]","Return of Excess Contribution—Fidelity HSA® | PDF",1789810363]