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HSA Request for Distribution - Imprinted # 70207

This form is used to document HSA distributions. Distributions from HSAs are subject to IRS reporting requirements and this form is designed to insure that you have all the necessary information. It contains detailed sections for type, amount, and method of distributions. Imprinting includes up to 4 lines of type (black ink). Two-part, one-sided, black ink, 8 1/2 x 11.