HSA Transfer and Withdraw Form Header Image

Click below to complete your Transfer or Withdraw Forms.

Click here to download the Transfer form

Download the transfer form and mail it to your current provider. Then click next to end this session. 

Click here to download the form

Download this form and then click Next to continue the withdraw process. 

Member Information

You will receive a confirmation email after completing this form
HSA Owner*
Please do not include dashes
Date of Birth*
Your member number can be found on your paper or electronic statements. If you do not have access to your statements, please call our Service Center at 1-800-676-2541

Transfer Information

Transfer Options*
No File Chosen
File uploads may not work on some mobile devices.

CD Penalties

Do you have any HSA Certificates with us? *
  • HSA funds currently held within a certificate of deposit will be subject to an early withdrawal penalty at time of transfer.
    • Terms 6 months = 3 months interest
    • Terms 12-24 months = 6 months interest
    • Terms greater than 24 months = 12 months interest
Do you want us to close them out and assess the penalties?*

Signature

I certify that all the information provided by me is true and accurate. All decisions regarding this transfer are my own, and I expressly assume responsibility for any consequences that may arise from this transfer. I agree that the IAA Credit Union, current acting custodian, is not responsible for any consequences that may arise from processing this transfer authorization. I confirm that funds transferred out of my HSA will be subject to penalty if said funds are held within a certificate of deposit.


CONSENT TO THE USE OF ELECTRONIC RECORDS, SIGNATURES AND DISCLOSURES: Underlying law requires that you first consent to the use of electronic signatures and electronic records before you enter into this account agreement. Please (Click here to review this agreement) and read the information carefully.

Name*
Use your mouse or finger to draw your signature above

Withdraw File Upload and Signatures

I certify that all the information provided by me is true and accurate. All decisions regarding this transfer are my own, and I expressly assume responsibility for any consequences that may arise from this transfer. I agree that the IAA Credit Union, current acting custodian, is not responsible for any consequences that may arise from processing this transfer authorization. I confirm that funds transferred out of my HSA will be subject to penalty if said funds are held within a certificate of deposit.


CONSENT TO THE USE OF ELECTRONIC RECORDS, SIGNATURES AND DISCLOSURES: Underlying law requires that you first consent to the use of electronic signatures and electronic records before you enter into this account agreement. Please (Click here to review this agreement) and read the information carefully.

Name*
No File Chosen
File uploads may not work on some mobile devices.
Use your mouse or finger to draw your signature above