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Click ‘Get Form’ to open the resubmission savings requesting document in the editor.
Begin by filling in your Account Holder’s Name and Address. Ensure all fields are completed accurately, including your SelectAccount ID #, Social Security # (if applicable), and contact information.
Specify the Distribution Amount Requested. Enter the exact dollar amount you wish to withdraw from your Health Savings Account.
Select a Distribution Reason from the provided options. Make sure to indicate if it is a Normal Distribution, Excess Contribution Removal, Disability, or any other reason that applies.
If applicable, complete the Beneficiary Information section for distributions related to death. Provide their name, address, and Social Security Number.
Review your Payment Information section carefully. Confirm that you understand how your request will be processed based on your account balance.
Finally, sign and date the form at the bottom to certify that all information is accurate before submitting it through our platform.

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