Health Savings Account (HSA) Tax Reporting Questionnaire Form
Please complete this Health Savings Account (HSA) Tax Reporting Questionnaire Form to provide essential information for your HSA tax reporting. Only the necessary details are collected—no sensitive account or government ID numbers.
Full Name
*
First Name
Last Name
Email Address
*
example@example.com
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Tax Year for Reporting
*
Please Select
2026
2025
2024
Did you make any HSA contributions during the tax year?
*
Yes
No
Total HSA contributions you made (excluding employer contributions)
Did your employer make contributions to your HSA?
Yes
No
Did you take any distributions from your HSA during the tax year?
*
Yes
No
Total HSA distributions taken
Were any HSA distributions used for non-qualified expenses?
Yes
No
Submit
Should be Empty: