HSA Transfer Request Form
To request a HSA Transfer or Rollover from a prior custodian, complete this form and submit to DataPath Financial Services.
An account transfer, or rollover, is how money or property can be moved to Summit from a Health Savings Account (HSA) or Medical Savings Account (MSA) previously held elsewhere.
The Internal Revenue Service limits how many rollovers can be taken, how quickly they must be completed, and how the Trustee or Custodian must report the transaction. By properly completing this form you are certifying that you have satisfied the rules and conditions applicable to your transfer/rollover and that you are making an irrevocable election to treat the transaction as a rollover.
Timelines – Funds received from a prior HSA or MSA must be deposited into the new HSA within 60 days (counting weekends and holidays) after receipt. Generally there are no exceptions to the 60-day rule, and the IRS cannot grant extensions. ‘Receipt’ generally means the day you actually have the funds in hand. For example, the 60 days would begin on the day you pick up a check from your prior Trustee or Custodian or on the day you receive the check in the mail.
12-Month Restriction – You can make one rollover distribution per year from a HSA account. Twelve (12) months must elapse between the time you receive a distribution of the assets to be rolled over and the time you can receive another distribution of the same assets for rollover purposes.
1. Download and complete this form. Be sure to sign it.
2. Submit the completed form to DataPath Financial Services in one of three ways:
• Email the form to email@example.com with the subject line "HSA Account Transfer."
• Fax the form to 501-687-1409.
• Mail the form to DataPath Financial Services, Inc., PO Box 55068, Little Rock, AR 72215.
3. IMPORTANT NOTE: A $25.00 HSA account closing fee will be deducted from your account balance before the
distribution is made.