HSA Application
Transfer Request - Complete this form to move your HSA assets from another financial organization to your HSA at WPCU.
Rollover Request - Complete this form if you currently have a Medical Savings Account (MSA), Flexible Spending Account (FSA) or Health Reimbursement Account (HRA) with another custodian and want to roll those funds over to your HSA at WPCU.
HSA Rollover Certification - Use this form if you have received funds from a distributing Health Savings Account (HSA), Archer Medical Savings Account (MSA), Flexible Spending Account (FSA), or Health Reimbursement Account (HRA) and want to roll those funds over to your HSA at WPCU.
Request for IRA Distribution to HSA - Use this form if you want to take money from a Traditional IRA or Roth IRA and directly move it to your HSA at WPCU. This movement is known as a "qualified funding distribution."
Adjustment Request - This form should be completed if you have made a mistaken contribution or mistaken distribution and need a correction.
Contribution Form - Use this form to make a contribution to your HSA for the prior tax year. This option is only available between January 1 and April 15.
Withdrawal Request - Complete this form if you would like to withdraw funds from your HSA. This includes withdrawals due to disability and when you have gone over your contribution limit and need to remove the excess funds to avoid incurring the tax penalties associated with exceeding the annual limit.
Beneficiary Form - Complete this form if you wish to change the beneficiaries on your HSA.
FlexBank HSA Financial Arrangements - If you have elected the Enhanced HSA and your employer is not currently paying the $2.00 monthly administrative fee, you can use this form to identify the account from which FlexBank will deduct this monthly fee.