The balance in your HSA is insured by the Federal Deposit Insurance Corporation FDIC Account Holder Information x0000x0000iiwVViiiVVVivx0000First NameMILast NameSocial Employee ID and Employer if app ID: 892890
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1 HSA - Death Distribution Request Form Th
HSA - Death Distribution Request Form The balance in your HSA is insured by the Federal Deposit Insurance Corporation (FDIC), Account Holder Information: �� i i w V À Þ V « i Ì i Ã Ì Ã Ã i V Ì Ü Ì - V V Õ Ì ` i À v À� Ì ° First Name _ MILast Name _ Social Employee ID and Employer (if applicable) $ G P G E K C T [ + P H Q T O C V K Q P � i i w V À Þ V « i Ì i Ã Ì Ã Ã i V Ì Ü Ì Ã À i À v À� Ì ° �� * i à i - i i V Ì i i w V À Þ / Þ « i _ _ Spouse _ Non-Spouse _ V « Þ v Ì i i Ì Ì i À /�� i Ã Ì i Ì À Þ Ã À i µ Õ À�� i ` Ì Û ` Ì i i Ý i V Õ Ì À à « ® _ MILast Name _ Street AddressCityStateZip CodeTelephone # À Û i À ½ à V i à i Processing Option: Please choose only one. + C O V J G U R Q W U G D G P G E K C T [ C P F + C O T G S W G U V K P I V J G C E E Q W P V V Q T G O C K P C P * 5 # C E E Q W P V By completing this section, I am requesting that a new HSA account be opened in my name. I will receive an HSA Enrollment Form to be completed and signed in Q T F G T V Q P C N K \ G V J G C E E Q W P V # H V G T V J G U G V W R K U E Q O R N G V G V J G * 5 # H W P F U T G O C K P K P I K P O [ U R Q W U G o U C E E Q W P V Y K N N D G V T C P U H G T T G F V Q + C O V J G U R Q W U G D G P G E K C T [ C P F + C O T G S W G U V K P I R C [ Q W V C P F E N Q U K P I Q H O [ J W U D C P F o U Y K H G o U * 5 # C E E Q W P V Amounts distributed will generally be included in my gross income, except for any amount used to pay for medical expenses I incur before the distribution date or medical expenses that were incurred by my spouse before death (and paid by me within one year after the date of death). + C O C P Q P U R Q W U C N D G P G E K C T [ T G S W G U V K P I R C [ Q W V I am required to include the funds received in my gross income, except for any amount used to pay for medical expenses incurred by the HSA Account holder (and paid by me within one year of the # E E Q W P V J Q N F G T o U F G C V J + H V J G T G K U P Q F G U K I P C V G F D G P G E K C T [ V J G G P V K T G C O Q W P V Q H V J G * 5 # U J C N N D G R C K F V Q V J G G U V C V G Q H V J G F G E G C U G F C P F K P E N W F G F Q P V J G F G E G F G P V o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whom funds are being distributed prior to completing the distribution. If the HSA consists of mutual funds, these funds will be liquidated and transferred/distributed as cash. Avidia Bank reserves the right to complete this liquidation at such time that is reasonable upon T G E G K R V C P F X G T K E C V K Q P Q H V J K U H Q T O & W G V Q V J G K O R Q T V C P V V C Z E Q P U G S W G P E G U T G N C V K P I V Q V J G F G C V J Q H C P * 5 # # E E Q W P V J Q N F G T + J C X G D G G P advised to see a tax professional. State tax laws may vary, and I agree that Avidia Bank makes no representation as to the tax effect of this distribution under state or federal law. The information provided is in general terms only to provide some information relating to the V C Z E Q P U G S W G P E G U Q H C F G E G F G P V o U * 5 # C E E Q W P V + P H Q T O C V K Q P R T Q X K F G F D [ O G K U V T W G C P F E Q T T G E V C P F O C [ D G T G N K G F W R Q P D [ # X K F K C $ C P M I assume full responsibility for this transaction and will not hold Avidia Bank liable for any adverse consequences that may result. K P F K X K F W C N C W V J Q T K \ G F V Q G Z G E W V G V J K U V T C P U C E V K Q P + J C X G T G C F C P F W P F G T U V C P F V J G K P U V T W E V K Q P U T W N G U C P F E Q P F K V K Q P U T G N C V K P I V Q V J K U Signature _______________________________________________________________________________ Date _______________________________Rev. 03/2020 Ã Ì À Õ V Ì Ã \ 1 à i Ì Ã v À��� Ì Õ Ì À â i ` Ã Ì À L Õ Ì v à à i Ì Ã v À� ` i V i ` i Ì ½ à - ] ` À i V Ì Þ Ì �� Þ Õ Ã Ì i L i i w V À Þ� ° \n « i Ì i à i V Ì Ã v Ì Ã v À������� ] Ì Ì V V i À Ì w i ` V « Þ v Ì i ` i Ì V i À Ì w V Ì i ` V « Þ v Þ Õ À V Õ À À i Ì « V Ì Õ À�� i ` v À Ü À ` Ì �� Û ` ] *����� ° " ° " 8 £ È £ Î ä Ì Ì i - « À } à ] Î Ó Ç £ È ° v L i i w V À Þ i ` Ì i V V Õ Ì ] v Õ ` Ã Ü L i « �� ` i V i ` i Ì \ V « Þ v Ì i i Ì Ì i À v ` Ã Ì À Ì ] À i Ì Ì i À v /��� i Ã Ì i Ì À Þ } \r Ý i V Õ Ì À É ` à Ì� À Ì À v Ì i ` i V i ` i Ì ½� à \r Ã Ì Ì i ��� Õ Ã Ì L i à i Ì Ì Ì i L Ã Ü i ° v Þ Õ Û i µ Õ i Ã Ì Ã À� i } À��� ` } L i i w V À Þ ` Ã Ì À L Õ Ì ] « i à i