HSA ACCOUNT REQUEST TO RETURN EXCESS CONTRIBUTIONS

HSA ACCOUNT REQUEST TO RETURN EXCESS CONTRIBUTIONS

Account Holder Instructions To initiate a Request to Return Excess Contributions from your BenefitWallet? Health Savings Account (HSA) complete this form and send the ORIGINAL form to The Bank of New York Mellon (BNY Mellon) at the address below. If you do not currently have a signature on file with BNY Mellon you must have your signature notarized. BNY Mellon will charge your account a check issuance fee* in accordance with the Health Savings Account Fee and Rate schedule.

Please allow 20 business days to process your request.

Note: The Bank of New York Mellon is required to report excess contributions returned to you on the Form 1099-SA (Distributions From an HSA, Archer MSA, or Medicare Advantage MSA) issued by The Bank of New York Mellon for the taxable year in which the excess contributions are actually returned to you not the taxable year for which the excess contributions were made. Neither an amended Form 5498-SA (HSA, Archer MSA or Medicare Advantage MSA Information) nor an amended Form 1099-SA will be issued to you for the taxable year for which the excess contributions were made. You should consult your personal tax advisor if you have any questions concerning how to report the return of excess contributions.

Send this completed and signed form (not a copy) to BNY Mellon at:

Mail:

BenefitWallet P.O. Box 535161 Pittsburgh, PA 15253-5161

Courier/Overnight:

BenefitWallet/HSA Operations 500 Ross Street Suite 154-0510 Pittsburgh, PA 15262-0001

* Note: A check issuance fee of $25, or as stated on your rate and fee schedule, will be deducted from your remaining account balance. If your account balance is not sufficient to cover the requested distribution plus the check issuance fee, you must submit a personal check (from an account other than your HSA) for $25, or the amount as stated on your rate and fee schedule, payable to Bank of New York Mellon with this form. Your account will remain open after the processing of a return of excess contributions and will remain subject to maintenance and other fees in accordance with the Health Savings Account Fee and Rate Schedule.

You have until the deadline for filing your individual income tax return (generally April 15th) plus extensions, to request a return of excess contributions. We must receive your request at least 5 business days before this deadline.

REC201306

HSA ACCOUNT REQUEST TO RETURN EXCESS CONTRIBUTION

Name: ________________________________________________________

HSA Checking Account Number:

9500_ _ _ _ _ _ _ _ _ _

Note: Your account number can be found in the upper right corner of your BenefitWallet Welcome Kit cover letter, monthly statements as well as on your BenefitWallet checks and deposit slips.

I request that The Bank of New York Mellon (BNY Mellon) process a return of excess contributions by issuing a check from my HSA account for the total amount shown below. The check should be sent to me at the address listed below.

The total distribution requested will be comprised of Contributions and Earnings as indicated below. In addition, I understand that a $25 check issuance fee will be assessed against my remaining account balance. In the event my remaining account balance is less than the total amount requested plus the $25 check issuance fee, the $25 will be deducted from my account before the distribution is processed unless a personal check for $25 accompanies this request.

Calendar Year for which excess contribution was made

(Note, a separate form must be submitted for each calendar year)

20________

Excess Contributions to be Returned to Account Holder

_,_ _ _._ _

Earnings on Excess Contribution to be Returned

_ _ _._ _

_,_ _ _._ _ Total Amount of Excess to be Returned to Account Holder

I authorize BenefitWallet to process a Return of Excess Contributions from the account indicated above. By completing, signing and submitting this form for processing, I authorize this distribution and the release of the requested funds.

Account Holder Name (Print)

Account Holder Signature Account Holder Address

Notary Public Signature*

On ___________________20__ before me, a notary public, appeared ______________________________, personally known to me or proved to me on the basis of satisfactory evidence to be the person whose name is subscribed to this document and acknowledged that he/she executed the same. Witness my hand and official seal/stamp,

Signature___________________________________________________ Notary Public

Notary Public Stamp or Seal *Required if you do not currently have a signature on file with BNY Mellon

Signature Verified by: _____________________

Date: ________________

FLEX Acct Disbursement Processed by: _____________________ Date: ________________

Check # ______________________

Amt ________________

REC201306

HSA-M-3123-0920

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