Transfer request form
Email, mail or fax completed forms to:
Email:
[email protected]Address: HealthEquity, Attn: Operations
PO Box 14374, Lexington, KY 40512
Fax: 801.846.2929
Use the transfer request form to transfer monies directly from another custodian into your HealthEquity® health savings account (HSA).
Part I—Primary account holder information *Required fields
Last name* First name* M.I. Gender Date of birth*
c Male c Female
Street address* City* State* ZIP*
Email address Daytime phone SSN or HealthEquity ID number*
( )
Employer name Health insurance company Coverage level Deductible amount
c Single c Family $
Part II—Transfer information
This request is for a custodian-to-custodian transfer or an employer-to custodian transfer. The monies currently held by another custodian are to
be directly transferred to an HSA at HealthEquity. Note: Your current custodian may require additional information prior to sending HealthEquity
the funds you are requesting. Please contact them to verify the additional information they may need.
Current custodian/Financial institution* Current custodian fax Daytime phone
( ) ( )
Address City State ZIP
Current HSA/IRA/MSA account number Amount to transfer
c Specific amount $ c Full amount (close my account)
Please indicate the account type that the monies will be coming from. (See rules and conditions for account types below.)
c IRA1 (individual retirement account) c MSA2 (medical savings account) c Another HSA2 (health savings account)
Current custodian instructions
Make check payable to HealthEquity and mail it to: HealthEquity, Attn: Operations, PO Box 14374, Lexington, KY 40512
Authorization
I authorize the transfer of assets in the manner described above and certify that all of the information provided by me is true and complete.
This transfer request may close my existing account defined in the Amount to Transfer section.
I authorize HealthEquity to open a Health Savings Account in my behalf and I accept the terms of the HealthEquity HSA Custodial Agreement
available at http://resources.healthequity.com/Forms/Agreements/HealthEquity_Custodial_Agreement.pdf. I understand that in compliance with
the USA Patriot Act, HealthEquity must verify the identity of all individuals who seek to open an HSA. I understand that as part of this identity
verification process, I may be asked to provide additional information and/or documentation before my account can be established.
Account holder signature* Date
Transfers
IRA—Beginning in 2007, individuals can make one lifetime transfer from their IRA to an HSA, subject to the contribution limits applicable for
1
the year of the transfer. Additional information can be found at www.irs.gov.
HSA/MSA—If you instruct the custodian of your HSA or MSA to transfer funds directly to the custodian of another HSA, the transfer is not
2
considered a rollover. There is no limit on the number of these transfers. You do not need to include the amount transferred in income, deduct
it as a contribution, or include it as a distribution on IRS Form 8889, line 12a.
Move It. Double It.
Get double interest on your HealthEquity® HSA. Just transfer or roll
over $250 or more from another HSA to HealthEquity and get up to
www.HealthEquity.com $25 total. Get full details at www.healthequity.com/double-it. 866.346.5800
04-01-34_Transfer_request_form_202307
