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HSA Contribution Form

The HSA Contribution Form provides instructions for submitting contributions to a HealthEquity health savings account (HSA), including options for payment via check or electronic funds transfer. It requires personal information from the primary account holder and includes an authorization section for the deposit. Contributions for the prior tax year are accepted until Tax Day of the following year, and processing may take three to five business days after submission.

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23 views1 page

HSA Contribution Form

The HSA Contribution Form provides instructions for submitting contributions to a HealthEquity health savings account (HSA), including options for payment via check or electronic funds transfer. It requires personal information from the primary account holder and includes an authorization section for the deposit. Contributions for the prior tax year are accepted until Tax Day of the following year, and processing may take three to five business days after submission.

Uploaded by

authurford
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
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HSA Contribution Form

Mail or fax completed forms to:


Address: HealthEquity, Attn: Member Services
PO Box 14374, Lexington, KY 40512
Fax: 801.727.1005

Primary Account Holder Information


Employer Name

Last Name First Name M.I.

Street Address City State ZIP

E-Mail Address (required) Daytime Phone SSN or HealthEquity ID Number


( )

Contributions
Contributions for the prior tax year are accepted until Tax Day of the following year. Funds
Contribution tax year: will be applied to the tax year of the date on the attached check if no year is indicated.

Banking Information
What method would you like to use to make contributions to your HSA?
c Option 1—Check
Include a check payable to HealthEquity with this form and mail to:
HealthEquity, Attn: Client Services, PO Box 14374, Lexington, KY 40512
Include the tax year and your HealthEquity ID number (6 or 7 digits) on the check.
When you provide a check as payment, you authorize HealthEquity to either use the information from your check to make a one-time, Back Office Conversion (BOC), electronic fund
transfer from your account if eligible, or to process the payment as a check transaction. Funds processed via BOC may be withdrawn from your account as soon as the same day your
payment is received.

c Option 2—One-time electronic funds transfer (EFT)


Fax this form and a copy of a voided check to:
HealthEquity, Attn: Member Services, 801.727.1005.
Account type: c Checking c Savings Amount of deposit: $

Financial institution:
City/state:
Routing number: Account number:
Voided check is required if your personal account is not on file.
c Option 3—Recurring monthly electronic funds transfer (EFT)
Fax this form and a copy of a voided check to HealthEquity, Attn: Member Services, 801.727.1005. Voided check is required if your personal
account is not on file.
Amount of deposit: $ Day of month funds should be pulled:
Financial institution: City/state:
Account type: c Checking c Savings Routing number: Account number:

Authorization
By signing below, I authorize the deposit of the above stated amount into my HealthEquity health savings account (HSA).
I understand the eligibility requirements of the type of HSA deposit I am making and state that I qualify to make the deposit.
I assume complete responsibility for:
1. Determining that I am eligible for an HSA each year I make a contribution.
2. Ensuring that all contributions I make are within the limits set forth by tax laws.
3. The tax consequences of any contribution (including rollover contributions) and distributions.
Name (please print) Signature Date

Please allow three to five business days after your form is processed by HealthEquity for your deposit to post to your account.

www.healthequity.com 866.346.5800
04-01-19_HSA_Contribution_Form_202306

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