MEDICAL SAVINGS ACCOUNT
TRANSFER/ROLLOVER REQUEST FORM

To request an MSA transfer or rollover, complete this request form and submit it to:
The Bancorp HSA
Attn: Medical Savings Accounts Department
409 Silverside Road, Suite 105
Wilmington, DE 19809

Important Information about Procedures for Opening a New Account:
To help the government fight the funding of terrorism and money laundering activities, Federal law requires all financial institutions to obtain, verify, and record information that indentifies each customer that opens an account. What this means for you: when you open an account, we will ask you your name,address, date of birth and other information that will allow us to idenitfy you. We may also ask to see your driver's license or other identifying documents. This information will be verified to ensure the identity of all persons opening an account. In certain instances, we are required to collect documents to fulfill our legal obligations. Documents provided in connection with your application will be used solely to establish and verify a customer's identity, and we shall have no obligation with respect to the terms of any such document.

Part I - Account Holder Information - Please Print

Customer Name: Social Security Number: Date of Birth:
Address: City: State: ZIP:
Home Phone: Work Phone: Branch Number: 304

Part II - Request Type

Trustee to Trustee Transfer: I currently have a Medical Savings Account with another Trustee or Custodian and want to transfer the funds directly to my MSA at the The Bancorp HSA.
(Proceed to Part III.)
Direct MSA to MSA Rollover: I currently have an MSA with another trustee and would like to directly transfer the funds to my MSA at the The Bancorp HSA.
(Proceed to Part III.)
MSA Rollover: I have been issued a check in the amount of $_______________ and closed my MSA account. I would like to rollover the funds to my MSA at the The Bancorp HSA.
(Proceed to Part IV - please attach a check payable to "The Bancorp HSA" when submitting this form.)

Part III - Transfer Information and Signature

Institution Name: Phone:
Address: City: State: ZIP:
Current MSA Account Number:

Transfer Instructions
Directly transfer: ___ALL or ___PART of my account in the following manner. If partial transfer list amount $_________.

This transfer ___WILL ___WILL NOT close my account.

Sign Here for Trustee to Trustee Transfer
I authorize the transfer of the MSA assets in the manner described above, and certify that all of the information provided by me may be relied upon by the Trustee or Custodian.
Account Holder - Signature Required: Date

Part IV - Rollover Information and Signature

Rollover Qualification Questions (For an eligible rollover, all questions must be answered NO)
1. Have more than 60 days elapsed since you received the distribution from the distributing MSA bank?
    Yes    No
2. Did you receive any other distributions from the distributing MSA during the preceding 12 months, which you also rolled over?
    Yes    No

Sign Here for Rollover
I have read and understand the rollover rules and conditions on this form and I have met the requirements for making a rollover. Due to the important tax consequences of rolling over funds or property to an MSA, I have been advised to see a tax professional. All information provided by me is true and correct and may be relied on by the Trustee or Custodian. I assume full responsibility for this rollover transaction and will not hold the Trustee or Custodian liable for any adverse consequences that may result. I hereby irrevocably designate this contribution and/or property as a rollover contribution.
Account Holder - Signature Required: Date

RULES AND CONDITIONS APPLICABLE TO ROLLOVER

GENERAL INFORMATION
A rollover is a way to move money or property from a Medical Savings Account (MSA) to a Medical Savings Account. The Internal Revenue Code (IRC) limits how many rollovers may be taken, how quickly rollovers must be completed, and how the Trustee or Custodian must report the transaction. By properly completing this form you are certifying to the Trustee or Custodian that you have satisfied the rules and conditions applicable to your rollover and that you are making an irrevocable election to treat the transaction as a rollover.

ROLLOVER

  1. Timelines
    The funds you receive from an MSA must be deposited into an MSA within 60 days after you receive them. When counting the 60 days, include weekends and holidays. There are generally no exceptions to the 60-day rule and the IRS cannot grant extensions. Receipt generally means the day you actually have the funds in hand. For example, the 60 days would begin on the day you pick up the check from the Trustee or Custodian or you receive the check in the mail.

  2. Twelve-Month Restriction
    You are entitled to one distribution per year per MSA which may be rolled over. Twelve (12) months must pass after receipt of one distribution which you rollover before you may take another distribution from the same MSA to rollover. The focus is on distributions out of an MSA. An MSA is created by executing a plan agreement, not by depositing a contribution into a separate investment with an existing MSA.

You are entitled to rollover the same assets only once in a twelve (12) month period. Twelve (12) months must elapse between the time you receive a distribution of the assets to be rolled over and the time you receive another distribution of those same assets for rollover purposes.

For Internal Use Only: Accepting MSA Custodian:
Our organization agrees to serve as the new Custodian for the account of the above named individual, and as Custodian, we agree to accept the assets being transferred.
The Bancorp HSA
409 Silverside Road, Suite 105
Wilmington, DE 19809

______________________________________   _____________________________
   Authorized Signature of New Custodian             Date

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