Get Hsa Bank Account Closing Form

HSA Bank Account Closing Form Instructions Use this form to remove all funds from your Health Savings Account HSA and close your account with Health Savings Administrators and HSA Bank. Complete this form and mail or fax it to Health Savings Administrators 10800 Midlothian Tpk Ste 240 Richmond VA 23235 Fax 804 726-1570. For assistance call 888 354-0697 Monday - Friday 8 30 a*m* - 5 p*m* ET. ACCOUNTHOLDER INFORMATION First Name MI Last Name Street Address City State Account Number OR ZIP Code Social Security Number Your remaining HSA balance less the 25 account closing fee will be mailed to you within three weeks of receiving this form* For additional assistance please contact Customer Service at 888 354-0697 Monday - Friday 8 30 a*m* - 5 p*m* ET. CLOSING REASON Account fees Interest rates No longer eligible to contribute to an HSA Customer service No longer have a high deductible health plan HDHP Have an insurance plan that uses a different HSA provider Transferring to another financial institution Other Transfer form from new institution is required* SIGNATURE I certify that I am the proper party to receive payment s from the HSA and that all information provided by me is true and accurate. I further certify that no tax advice has been given to me by the Custodian* All decisions regarding this withdrawal are my own* I expressly assume the responsibility for any adverse consequences which may arise from this withdrawal and I agree that the Custodian shall in no way be held responsible. Complete this form and mail or fax it to Health Savings Administrators 10800 Midlothian Tpk Ste 240 Richmond VA 23235 Fax 804 726-1570. For assistance call 888 354-0697 Monday - Friday 8 30 a*m* - 5 p*m* ET. ACCOUNTHOLDER INFORMATION First Name MI Last Name Street Address City State Account Number OR ZIP Code Social Security Number Your remaining HSA balance less the 25 account closing fee will be mailed to you within three weeks of receiving this form* For additional assistance please contact Customer Service at 888 354-0697 Monday - Friday 8 30 a*m* - 5 p*m* ET. For assistance call 888 354-0697 Monday - Friday 8 30 a*m* - 5 p*m* ET. ACCOUNTHOLDER INFORMATION First Name MI Last Name Street Address City State Account Number OR ZIP Code Social Security Number Your remaining HSA balance less the 25 account closing fee will be mailed to you within three weeks of receiving this form* For additional assistance please contact Customer Service at 888 354-0697 Monday - Friday 8 30 a*m* - 5 p*m* ET. CLOSING REASON Account fees Interest rates No longer eligible to contribute to an HSA Customer service No longer have a high deductible health plan HDHP Have an insurance plan that uses a different HSA provider Transferring to another financial institution Other Transfer form from new institution is required* SIGNATURE I certify that I am the proper party to receive payment s from the HSA and that all information provided by me is true and accurate. CLOSING REASON Account fees Interest rates No longer eligible to contribute to an HSA Customer service No longer have a high deductible health plan HDHP Have an insurance plan that uses a different HSA provider Transferring to another financial institution Other Transfer form from new institution is required* SIGNATURE I certify that I am the proper party to receive payment s from the HSA and that all information provided by me is true and accurate. I further certify that no tax advice has been given to me by the Custodian* All decisions regarding this withdrawal are my own* I expressly assume the responsibility for any adverse consequences which may arise from this withdrawal and I agree that the Custodian shall in no way be held responsible. .