HSA TRANSFER REQUEST - Patelco Credit Union
HSA TRANSFER REQUEST #3302 (1/2011) ©2011 Ascensus, Inc., Brainerd, MN RECIPIENT’S NAME AND ADDRESS (Individual requesting the transfer) I authorize the transfer of the HSA assets in the manner described above and certify that all of the information provided by me is correct and may be relied upon by the Custodian. ................
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