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HSA withdrawal correction form

HSA withdrawal correction form

This form can be used to redeposit funds withdrawn in error and cannot be used to correct an Excess Contribution Return. Funds will be posted as a correction and not as a contribution. The deposit will be entered for the year the distribution occurred.

Questions? Please call us at the number on the back of your debit card if you have any questions while completing this form.

Important Note: Please do not provide any card information on this form as forms with debit card numbers will not be processed and will be destroyed for your protection.

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