Health Savings Account (Hsa) Excess Contribution Removal Form
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1Health Savings Account (HSA)
Excess Contribution Removal Form
Instructions: Complete this form to remove excess contributions from your account.
Mail or fax completed form to:
Health Savings Administrators
10800 Midlothian Turnpike, Suite 240 • Richmond, VA 23235
Fax: 804.726.1570
Account Holder Information
Requirements
First Name ________________________________________ Last Name __________________________________________ M.I. ________
Street Address _________________________________________________________________________ Apt / Suite ___________________
City
State
ZIp Code
____________________________________________________________________
_____________________
__________________________
Social Security Number ________ – ______ – ______________
OR
Account Number ________________________________________
Excess Contribution Removal
Funds contributed in excess of your contribution limit are subject to penalty and tax unless the excess and any earnings are withdrawn
by you prior to the due date (including extensions) for filing your federal income tax return. You should consult a qualified tax professional
for advice on your excess contribution removal.
NOtE: The Internal Revenue Service requires FpS Trust to report withdrawals that are considered refunds of excess contributions. In
order for the withdrawal to be accurately reported, you may not withdraw the excess directly. Instead, you must request an excess
contributions refund by faxing or mailing this signed and completed form to Health Savings Administrators, using the address or fax
number listed above.
A $25 excess contribution removal fee will be deducted from your account.
please send me a check for the amount indicated below, plus any applicable earnings.
Excess Contribution Amount $________________
tax Year ___________
Health savings accounts (HSA) contribution maximums are determined by the IRS. For more information, please visit the U.S.
Department of the Treasury website,
Signature
By signing below, I hereby authorize a refund of the excess contribution specified above, plus any earnings on the requested amount.
______________________________________________________________
______ / ______ / ____________
Account Holder Signature
Date
(mm|dd|yyyy)
Rev. 01/2015
10800 Midlothian Turnpike, Suite 240
Richmond, VA 23235
(p) 888.354.0697
(f) 804.726.1570
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