ACS|BNY Mellon Health SavingsAccountTrustee-to-Trustee TransferForm
Transfer FROM ACS|BNY Mellon Health SavingsAccount
AccountholderInstructions Completethisform byenteringthe“AccountholderInformation”below,andsendoriginaltoTheBankofNewYorkMellontoinitiateatrustee-to-trusteetransferoffundsfromyour ACS|BNYMellonHealthSavingsAccount(HSA)toanewcustodianortrustee. Check with your future trustee for any additional information required. The Bank of New York Mellon will sendfundsto the new trustee via check. The Bank of New York Mellon will charge your account a check issuance fee inaccordancewith the Health Savings Account Fee and Rate schedule. Please allow 20 business days forprocessing.
Accountholder Information, Transfer Instruction &Authorization
ACS|BNY Mellon HSA Solution AccountNumber9 5 00
Youraccountnumbercanbefoundintheupperrightcornerof yourACS|BNYMellonHSASolutionWelcomeKitcoverletter,monthlystatementsaswellason yourACS|BNYMellonHSASolutionchecksanddepositslips.
Transfer Request andAuthorization
Transfer100%ofmyaccountbalanceandclosemyaccount*
Transfer$_,
_._
*Note:Ifyourbalanceislessthanthe$25feethathasbeendisclosed,youraccountwillbeclosedandtherewillbenocheck issued. Monthly maintenance fees will continue to be assessed in accordance with the disclosures and feescheduleuntiltheaccountisclosed.Thismayimpacttheamountofthetransferredbalance.Iunderstandanyfundsthatmayhavebeen invested in Dreyfus investment funds, I need to request transfer to The Bank of New York Mellon account priortosubmissionofthisauthorizationtoensurepropermovementoffundsand1099distributionreporting.
Transfer fundsto:
Trustee/CustodianNameAddress
City, StateZip
AccountNumber
Iauthorize ACS|BNYMellonHSASolutiontotransactuponmyaccount,totransferfundsfromthespecifiedaccountto the Trustee/Custodian and account as indicatedabove.
Accountholder Name(Print)AccountholderSignature
Stamp of SignatureGuaranteeRequired whenaccountholdersignature is not onfile
Send this completed signed form to The Bank of New York Mellonto:
MailCourier/Overnight
ACS|BNY Mellon HSASolutionACS|BNY Mellon HSASolution
P.O. Box4038135 Santilli Highway026-0019
Woburn, MA01888-4038Everett, MA02149
FORM:TO0907