[{"data":1,"prerenderedAt":-1},["ShallowReactive",2],{"detail-sidebar-cat-1-en-105":3,"doc-seo-302347-105":53,"doc-detail-302347-en":126},{"code":4,"msg":5,"data":6},0,"success",[7,14,19,24,29,34,39,44,49],{"id":8,"doc_module":9,"doc_module_name":10,"category_name":11,"show_sort_weight":12,"slug":13},11,1,"Template","Presentations",90,"presentations",{"id":15,"doc_module":9,"doc_module_name":10,"category_name":16,"show_sort_weight":17,"slug":18},12,"Resumes",80,"resumes",{"id":20,"doc_module":9,"doc_module_name":10,"category_name":21,"show_sort_weight":22,"slug":23},14,"Invoices",70,"invoices",{"id":25,"doc_module":9,"doc_module_name":10,"category_name":26,"show_sort_weight":27,"slug":28},15,"Posters",60,"posters",{"id":30,"doc_module":9,"doc_module_name":10,"category_name":31,"show_sort_weight":32,"slug":33},16,"Social Media",50,"social-media",{"id":35,"doc_module":9,"doc_module_name":10,"category_name":36,"show_sort_weight":37,"slug":38},17,"Forms",40,"forms",{"id":40,"doc_module":9,"doc_module_name":10,"category_name":41,"show_sort_weight":42,"slug":43},18,"Letters",30,"letters",{"id":45,"doc_module":9,"doc_module_name":10,"category_name":46,"show_sort_weight":47,"slug":48},21,"Paper Templates",5,"papers-templates",{"id":50,"doc_module":9,"doc_module_name":10,"category_name":51,"show_sort_weight":4,"slug":52},158,"General","general-158",{"code":4,"msg":54,"data":55},"ok",{"site_id":56,"language":57,"slug":58,"title":59,"keywords":60,"description":61,"schema_data":62,"social_meta":119,"head_meta":121,"extra_data":123,"updated_unix":125},105,"en","wealthcare-saver-hsa-distribution-of-excess-or-mistaken-contribution-form-fill-out-to-request-refund","WealthCare Saver HSA - Distribution of Excess or Mistaken Contribution Form - Fill Out to Request Refund","","Request the return of HSA excess or mistaken contributions by completing this Distribution of Excess Contribution form. The form captures account holder identity, the excess amount and required earnings, and disbursement instructions for either direct deposit (electronic transfer) or mailed checks. Signatures certify the holder’s authorization, accuracy of provided information, and responsibility for the distribution outcome, along with acknowledgment of custodial agreement terms and applicable fee deductions.",{"@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/wealthcare-saver-hsa-distribution-of-excess-or-mistaken-contribution-form-fill-out-to-request-refund/302347/",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/wealthcare-saver-hsa-distribution-of-excess-or-mistaken-contribution-form-fill-out-to-request-refund/302347.png","ImageObject",442,249,{"name":88,"@type":89},"Bill Black","Person",{"url":68,"name":91,"@type":92},"DocShare","Organization","application/pdf","2026-09-26","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},"Who must complete this HSA distribution form and when?","Question",{"text":108,"@type":109},"The account holder must complete the form. It is used when contributions exceed the IRS annual limits and the over-contributed funds need to be returned.","Answer",{"name":111,"@type":106,"acceptedAnswer":112},"What details are required for the excess contribution amount?",{"text":113,"@type":109},"You must provide the excess amount being removed and the earnings on that excess. The IRS requires excess HSA distributions to include earnings.",{"name":115,"@type":106,"acceptedAnswer":116},"How can the returned funds be disbursed?",{"text":117,"@type":109},"Funds are deposited electronically to the direct deposit bank account on file; if no bank account exists, a check is mailed. The mailing address is provided on the form.","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},302347,1789792127,{"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":79,"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":125,"read_time":9},24189269381491,"https://ap-avatar.wpscdn.com/avatar/160000cf11732dd8392?x-image-process=image/resize,m_fixed,w_180,h_180&k=1788146458752108895","Distribution of Excess Contribution  \nMust be filled out by Account Holder  \nThe IRS specifies the total annual contribution limits which can be made each year. You can find those limits online [at www.IRS.gov. If you](at www.IRS.gov. If you) have exceeded the contribution limit, please complete this form to request the over contributed funds be 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](www.irs.gov/pub/irs-pdf/p969.pdf).  \nFax completed form to:  \n855.588.1028  \nMail completed form to:  \nWealthCare Saver  \nP.O. Box 162177 Altamonte Springs, FL 32716  \nQuestions about this form?  \n(888) 722-1223  \n8:00 AM to 5:00 PM MT  \nHolder Information  \nSection 1: Account  \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)*  \n*IRS 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.  \n Section 3: Disbursement Instructions Tran Code 155 (Distribution of Excess Contribution)   \n Deposit funds electronically to the direct deposit bank account on file.  \n*Please note: If no bank account, a check will be mailed.  \n Mail checks to the address above  \nSection 4: Signature  \nI certify that I am the HSA account holder and legally authorized to receive payment(s) from this HSA account 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 account. I understand that any applicable fees will be deducted from the distribution amount requested. (See HSA Fee Schedule on the Portal) .  \n    /   /   SIGNATURE OF HSA ACCOUNT HOLDER DATE  \n*WealthCare Saver is a dba ofAlegeus Technologies, LLC, a licensed Non-Bank Custodian  \nRev. 042021  \n2","cbCaigiWB3VkoRpg","https://ap.wps.com/l/cbCaigiWB3VkoRpg","pdf",237192,"English","# Holder Information\n## Section 1: Account\n## Section 2: Excess Contribution Information\n## Section 3: Disbursement Instructions\n## Section 4: Signature","[{\"question\":\"Who must complete this HSA distribution form and when?\",\"answer\":\"The account holder must complete the form. It is used when contributions exceed the IRS annual limits and the over-contributed funds need to be returned.\"},{\"question\":\"What details are required for the excess contribution amount?\",\"answer\":\"You must provide the excess amount being removed and the earnings on that excess. The IRS requires excess HSA distributions to include earnings.\"},{\"question\":\"How can the returned funds be disbursed?\",\"answer\":\"Funds are deposited electronically to the direct deposit bank account on file; if no bank account exists, a check is mailed. The mailing address is provided on the form.\"}]","WealthCare Saver HSA - Distribution of Excess or Mistaken Contribution Form - Fill Out to Request Refund | PDF"]