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Click ‘Get Form’ to open the Health Savings Account (HSA) Transfer Request Form in the editor.
Begin by filling out the Account Information section. Enter your full name, employer name, Social Security number, telephone number, and address details including city, state, and zip code. Ensure all required fields marked with an asterisk are completed.
Proceed to the Existing HSA/IRA Trustee or Custodian Information section. Provide the name of your current HSA/IRA trustee or custodian along with your account number and their contact information.
If applicable, complete the Former Spouse Information section if you are transferring funds due to a divorce settlement. Include necessary details such as their name, address, date of birth, and Social Security number.
In the Transfer Instructions section, specify whether you want to transfer all or part of your HSA/IRA funds. Indicate who should receive the funds and provide any necessary payment instructions.
Finally, sign and date the form in the Transfer Signature section to authorize the transfer. Make sure to review all information for accuracy before submission.

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Versions	Form popularity	Fillable & printable
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2018	4.1 Satisfied (56 Votes)

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