TRANSFER REQUEST Transfer from: HSA Distribution Plan Number: ______________ ______________ ______________ ______________ ______________ ______________ (Note: Please list all accounts numbers to be transferred to GBC ) Distribution amount type: Entire Plan Other _________________________________________________________ (Note: Please Select One ) Dollar Amount Date: _________ Distribution time frame: Immediately (Note: Please Select One ) Distributing Institution: Institution Name: ________________________________________________________________________________________________ Primary Address ________________________________________________________________________________________________ Secondary Address: ______________________________________________________________________________________________ City: _________________________________________ State: _________ Postal Code: __________________ Payment Method to GBC Bank: Mail check ACH Wire Transfer (Note: Please Select One ) FOR INTERNAL USE ONLY *ACCOUNT OWNER #1: DESCRIPTION OF *ACCOUNT OWNER #2: DESCRIPTION OF IDENTIFICATION DOCUMENTS USED (Note: Copy of I.D. to accompany signature card.) IDENTIFICATION DOCUMENTS USED (Note: Copy of I.D. to accompany signature card.) *Type: *Type: *ID#: *ID#: *Issue Place: *Issue Place: *Issue Date: *Issue Date: *Expiration: *Expiration: CONTRIBUTION TYPE: (for new accounts only) REGULAR ROLLOVER DIRECT ROLLOVER TRANSFER CONVERSION DEATH TRANSFER TAX YEAR CONTRIBUTION: CURRENT YEAR PREVIOUS YEAR (for new accounts only) INSURANCE COVERAGE: SELF-ONLY FAMILY INSURANCE EFFECTIVE DATE: First ACH contribution date from employer: