Health Savings Account Transfer Request Form - Benefit Extras 2026

1. Click ‘Get Form’ to open the Health Savings Account Transfer Request Form in the editor.
2. Begin by filling out the Account Information section. Enter your employer name, accountholder name, social security number, telephone number, and address details accurately.
3. Proceed to the Existing HSA/IRA Trustee or Custodian Information section. Provide the name of your current trustee or custodian, account number, and their contact information.
4. If applicable, complete the Former Spouse Information section with their details and include a copy of the divorce decree if they are receiving funds through a settlement.
5. In Step 4a, specify transfer instructions. Indicate whether you want to transfer all or part of your HSA/IRA funds and provide necessary payment details.
6. For asset liquidation instructions in Step 4b, indicate if you want all assets liquidated immediately or provide specific instructions for each asset.
7. Finally, sign and date the form in Step 5 to authorize the transfer. Ensure all information is accurate before submission.

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