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KeyBank HSA Transfer Form

This document is a transfer form to move a health savings account (HSA) from another custodian to KeyBank. The form requests information about the account holder and current custodian. It asks which type of account is being transferred - an HSA, IRA, or medical savings account. Instructions are provided for the current custodian to identify specific accounts and balances to transfer. Once completed, KeyBank agrees to serve as the new custodian and accept the transferred assets.

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michele
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209 views1 page

KeyBank HSA Transfer Form

This document is a transfer form to move a health savings account (HSA) from another custodian to KeyBank. The form requests information about the account holder and current custodian. It asks which type of account is being transferred - an HSA, IRA, or medical savings account. Instructions are provided for the current custodian to identify specific accounts and balances to transfer. Once completed, KeyBank agrees to serve as the new custodian and accept the transferred assets.

Uploaded by

michele
Copyright
© All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd

KeyBank Health Savings Account (HSA)

Transfer Form
Please complete this form if you are transferring your Health Savings Account from another trustee or custodian to KeyBank. Attach a recent account
statement to this document to help your current custodian identify the assets you wish to transfer.
Bank Number: Social Security Number:
(to be completed by a bank employee)

ACCOUNT
HOLDER
INFORMATION Name

Address

City State Zip

RESIGNING PLAN Please indicate the name and address of your current HSA or Medical Savings Account (MSA) Custodian. (This information
TRUSTEE OR may be found on your last statement.)
CUSTODIAN
Name

Address

City State Zip

TYPE OF PLAN Currently, any amount of another HSA or MSA may be transferred to this HSA. Only the amount of your annual contribution may be
YOU ARE transferred from an IRA
TRANSFERRING
✘ Health Savings Account IRA Medical Savings Account

INSTRUCTIONS FOR Please use this area to indicate the account numbers that you are interested in transferring to KeyBank. This is especially useful if you have
CURRENT more than one investment indicated on the attached statement.
CUSTODIAN
1
Bank Account
Account Number $ Entire Balance?
Yes ✘ □ No □
Close account: Only at maturity □ Immediately □ (Certain bank penalties may apply)
2
Bank Account
Entire Balance?
Account Number $
Yes □ No □
Close account: Only at maturity □ Immediately □ (Certain bank penalties may apply)
3 KeyBank cannot accept assets “in-kind”.
Brokerage
Account Account
Number
□ Sell all assets or □ Sell the following asset(s) only:

ACCOUNT HOLDER
SIGNATURE
Signature Date

ACCEPTANCE/
DELIVERY
(To be completed KeyCenter Name Attention
by KeyBank)
Address City State Zip

Please be advised that KeyBank agrees to serve as the new Custodian for the account of the above-named individual, and as
successor Custodian, we agree to accept the assets as specified on this form. Please make the check payable to KeyBank,
Custodian, F/B/O Plan Holder Name and send it to the address in the Delivery section above.

Authorized KeyBank Signature Date


Original – Resigning Trustee or Custodian Copy to – Customer Copy to – KeyCenter
PRINT CLEAR Form No. EF-71-8047

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