Transcription of CONTRIBUTION AND INVESTMENT SELECTION - Elements …
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CONTRIBUTION AND INVESTMENT SELECTION - Elements …
Page 1 of 23107 / 2614H (Rev. 5/2012) 2012 Ascensus, AND INVESTMENT SELECTIONPART 1. HSA OWNERName (First/MI/Last)_____Social Security Number _____Date of Birth _____ Phone _____Email Address_____Account Number_____ Suffix_____PART 2. HSA TRUSTEE OR CUSTODIANTo be completed by the HSA trustee or custodianName _____Address Line 1 _____Address Line 2 _____City/State/ZIP_____Phone_____ Organization Number _____PART 3. CONTRIBUTION INFORMATIONC ontribution Amount _____ CONTRIBUTION Date _____ CONTRIBUTION TYPE (Select one)1. Regular(Includes catch-up contributions as well as qualified HSA funding distributions from an IRA) CONTRIBUTION for Tax Year _____ (Qualified HSA funding distributions from an IRA must be made for the current tax year) 2.
Contribution for Tax Year _____ (Qualified HSA funding distributions from an IRA must be made for the current tax year) 2. Rollover (Distribution from an HSA or Archer MSA that is being deposited into this HSA) ... 3107_2614H HSA Contribution and Investment Selection (5/2012)
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ResCare, Inc. Retirement Savings Plan, Contribution, Investment, And Investment Selection, Investment selection, Defined Contribution Plans Investment Policy Statement, Selection, 401(k) basics, Rollover Contribution Form Instructions, Transfer/Rollover/Exchange Form Instructions, CONTRIBUTION AND INVESTMENT SELECTION, Rev. 10/2014, Performance Attribution Analysis