Administrative Forms

HSA Custodial Booklet Set Form # 40-HSA Revised 5/08

HSA Custodial Booklet Set

This form can be imprinted. Call 800-346-3961 for details.

Package contains 25 forms. Call for quantity pricing or for imprint orders.

HSA Trust Booklet Set Form # 41-HSA Revised 5/08

HSA Trust Booklet Set

This form can be imprinted. Call 800-346-3961 for details.

Package contains 25 forms. Call for quantity pricing or for imprint orders.

HSA Custodial Self-Directed Booklet Set Form # 42-HSA Revised 5/08

HSA Custodial Self-Directed Booklet Set

This form can be imprinted. Call 800-346-3961 for details.

Package contains 25 forms. Call for quantity pricing or for imprint orders.

HSA Power of Attorney Form # 43-HSA Revised 10/06

HSA Power of Attorney Form

This form can be imprinted. Call 800-346-3961 for details.

Package contains 25 forms. Call for quantity pricing or for imprint orders.

HSA Contribution Form # 54-HSA Revised 5/08

HSA Contribution Form

Who can make the HSA Contribution? Any eligible individual may contribute to an HSA. For an HSA established by an employee, the employee, the employee's employer or both may contribute to the HSA of the employee in a given year. For an HSA established by a self-employed (or unemployed) individual, the individual may contribute to the HSA. Family members may also make contributions to an HSA on behalf of another family member as long as that other family member is an eligible individual. In Notice 2004-50, the IRS set forth the rule that any person can make an HSA contribution for another person; it is not required that they be afamily member

This form can be imprinted. Call 800-346-3961 for details.

Package contains 25 forms. Call for quantity pricing or for imprint orders.

Instruction & Authorization to Transfer HSA Funds Form # 56-HSA Revised 01/05

Instruction & Authorization to Transfer HSA Funds
This form can be imprinted. Call 800-346-3961 for details.

Package contains 25 forms. Call for quantity pricing or for imprint orders.

HSA Distribution Form # 57-HSA Revised 05/07

HSA Distribution Form
This form can be imprinted. Call 800-346-3961 for details.

Package contains 25 forms. Call for quantity pricing or for imprint orders.

Change in Designated Beneficiary Form # 61-HSA Revised 01/05

Change in Designated Beneficiary Form

This form can be imprinted. Call 800-346-3961 for details.

Package contains 25 forms. Call for quantity pricing or for imprint orders.

Certification of Mistaken HSA Distribution Form # 64-HSA Revised 06/05

Certification of Mistaken HSA Distribution
This form can be imprinted. Call 800-346-3961 for details.

Package contains 25 forms. Call for quantity pricing or for imprint orders.

HSA Certification for Rollover to an HSA Form # 65-HSA Revised 05/05

HSA Certification for Rollover to an HSA
This form can be imprinted. Call 800-346-3961 for details.

Package contains 25 forms. Call for quantity pricing or for imprint orders.

Certification for One Lifetime Transfer of IRA Funds to an HSA Form # 66-HSA Revised 08/07

Certification for One Lifetime Transfer of IRA Funds to an HSA

Purpose of Form: This form provides certification that a distribution from a traditional or Roth IRA is exempt from income tax, because the distribution meets the one lifetime transfer rules under the Health Opportunity Patient Empowerment Act of 2006.

This form can be imprinted. Call 800-346-3961 for details.

Package contains 25 forms. Call for quantity pricing or for imprint orders.

HSA Special Explanation Regarding Withdrawal of Excess HSA Contribution Form # 67-HSA Revised 03/07

HSA Special Explanation Regarding Withdrawal of Excess HSA Contribution
This form can be imprinted. Call 800-346-3961 for details.

Package contains 25 forms. Call for quantity pricing or for imprint orders.

HSA Beneficiary Designation (Attach to Plan Application) Form # 40-A-HSA Revised 5/08

HSA Beneficiary Designation (Attach to Plan Application)

This form can be imprinted. Call 800-346-3961 for details.

Package contains 25 forms. Call for quantity pricing or for imprint orders.