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Putting her first since 2017

HEALTH SAVINGS ACCOUNT FORMS

Forms related to your Health Savings Account

Health Savings Account Forms

 

Download the form you need by clicking the link below. Return the completed form in person at a branch, fax it to us (415-674-4691), or mail it to:

SF Fire Credit Union

3201 California Street

San Francisco, CA 94118

COVER SHEET

Please fill out this cover sheet as your first step to opening an HSA account.

 

To download the PDF, click here

APPLICATION PACKET

Fill out this application packet to open an HSA account.

 

To download the PDF, click here

BENEFICIARY DESIGNATION OR CHANGE

This form lets you add, change, or remove a beneficiary from your HSA account

 

To download the PDF, click here

CHANGE NOTICE

This form lets you document changes to HSA owner information and account status

 

To download the PDF, click here

CONTRIBUTION AND INVESTMENT SELECTION

If you'd like to make a contribution to an HSA, use this form to designate which HSA product to place your funds.

 

To download the PDF, click here

ROLLOVER TRANSFER CONTRIBUTIONS

Are you rolling or transferring your HSA from another institution or employer? Use this form to transfer or rollover funds.

Note: Rollover indicates that you are bringing your HSA from one financial institution to another without needing a check in hand. Transferring indicates that the funds come from a financial institution in the form of a check that you are presenting.

To download the PDF, click here

WITHDRAWAL INSTRUCTIONS

Use this form to provide information on HSA withdrawals. Penalties may apply. Learn more about withdrawals here.

 

To download the PDF, click here

The total annual contribution limit for 2019 is $3,500 for an individual, $7,000 for families. The catch-up limit is $1,000 for both individuals and families.

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As a local credit union, we measure our success one member at a time. We want to get to know you and help you achieve your goals. Come into a branch or call us today. Our people are happy to serve you.

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