IRA to HSA Transfer Form
409 Silverside Rd, Suite 105
Wilmington, DE 19809

P. 800.555.9316
F. 302.385.5121
Banking Services Provided by
The Bancorp Bank,
MEMBER FDIC, EQUAL HOUSING LENDER
Please allow four to six weeks for completing the transfer. Time frame is based on prior custodian/trustees' processing time.
  PART 1: Personal Information
First Name: MI: Last Name:
Address: (We do not recognize a PO box as a street address)
City: State: Zip:
Date of Birth: SSN:
Work Phone: Home Phone: Email:
  PART 2: Guidelines for Transferring an IRA to an HSA
  1. IRA transfers must be a direct trustee to trustee/custodian transfer.
  2. You are allowed a one-time transfer from an IRA to an HSA.
  3. The transfer is limited to the maximum HSA contribution for the year, and the amount contributed is not allowed as a deduction. Your total HSA contributions and the IRA transfer cannot exceed the HSA contribution maximum.
  4. The IRA transfer will not be included in income or subject to the early withdrawal additional tax.
  5. If an individual electing the one-time transfer does not remain eligible to contribute to their HSA for the 12 months following the month of the contribution ("the Testing Period"), the transferred amount will be included in income and subject to a 10 percent additional tax.
  6. Only transfers from a Traditional IRA, as defined in Internal Revenue Code Section 408(a), are permitted at this time.
  PART 3: Transfer from: IRA Trustee of Custodian
Institution Name:
Address: (We do not recognize a PO box as a street address)
City: State: Zip:
Phone Number: IRA Account Number:
  PART 4: Transfer to: The Bancorp HSA
The Bancorp HSA Routing #:    031101114 The Bancorp HSA Account #:
Amount of Transfer $: Type of Transfer:
(Transfer amount cannot exceed annual contribution maximum. See www.thebancorphsa.com for current contribution maximum)
  PART 5: Authorization Statement
Before signing below, please consult your tax advisor to discuss the potential tax consequences that could result if the transfer is deemed ineligible or you become ineligible during the Testing Period, defined above in guideline 5.
I authorize The Bancorp HSA to transfer fund as designated above from my IRA to my health savings account with The Bancorp HSA. I understand that the transfer is subject to the annual contribution limit, and I accept any tax consequences that could result if the above transfer is not qualified rollover from my IRA.
Signature of Account Holder: Date:
  PART 6: Accepting HSA Custodian
Our organization serves as the Trustee to Custodian for a health savings account of the above-named individual, and as Trustee or Custodian, we agree to accept the assets being transferred. The Bancorp HSA, 409 Silverside Road, Suite 105, Wilmington, DE 19809
Authorized Signature of New Trustee or Custodian: Date:
Please mail your opening deposit check made payable to The Bancorp HSA in a postage-paid envelope,
or send it to The Bancorp HSA, 409 Silverside Road, Suite 105, Wilmington, DE 19809

Banking Services Provided by The Bancorp Bank. Member FDIC. Equal Housing Lender.