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Transaction Summary (1)

Transaction Summary
	From	To	Expense	Amount	Remove
Show details for $1,000.00 transaction from My HSA to Me (Check)	My HSA	Me (Check)	Dental	$1,000.00	Remove
Transaction Details Frequency: One-Time
	Total Amount			$1,000.00

Normal Distribution Disclaimer

Agreed

I certify I am the HSA account holder, beneficiary or other individual authorized to execute this distribution request. I am claiming reimbursement only for eligible expenses incurred during the applicable coverage period for myself and/or my legal dependent(s) under the plan. These expenses have not previously been reimbursed or will not be reimbursed under any other benefit plan, and will not be claimed as an income tax deduction. I certify that I am responsible for any consequences resulting from this distribution. I understand that my designated representative or custodian/trustee cannot provide legal advice. I indemnify and agree to hold the custodian/trustee and their designated representative harmless against any liabilities. I confirm that the financial transaction I am about to initiate is for domestic purposes only and will not be sent internationally. Timing/Market Value Fluctuation of Distributions Distributions from your cash account will generally be made within 72 hours of your request. If you use a debit card, funds in your cash account are available immediately. If it is necessary to sell investments and transfer funds to your cash account in order to cover your distribution request, this may take up to 6 business days. The amount received for your distribution request, which involves the sale of investments, may be less than your full distribution amount requested, due to market value fluctuation. Redemption Fees Sales of mutual funds may result in redemption fees if trades occur within specific periods established by certain mutual funds. These redemption fees exist to protect the interests of long-term shareholders by discouraging market timing and excessive trading abuses through the imposition of penalties on rapid in-and-out trades. See the mutual fund prospectus for more information on redemption fees.

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AccountsTransaction Summary

Cash Account

Investment Account