The HSA Bank contribution form is a one-page document you use to deposit personal money into your Health Savings Account outside of payroll. Download it after logging in at myaccounts.hsabank.com, fill in your account details, the dollar amount, and the tax year, sign it, then either mail it with a check or skip the paper and move the same funds through the Member Website.
Where to Get the Form and How to Submit It
You can pull the form from the HSA Bank Member Website or request a copy through your employer’s benefits portal. Once it’s complete, you have two ways to send it in.
By Mail
Print the form, write a personal check payable to “HSA Bank,” and put your HSA account number on the memo line so the two can be matched if they get separated. Mail both to:
HSA Bank
909 N 8th Street, Suite 200
Sheboygan, WI 53081-40561HSA Bank. Contact Us – Customer Support
Allow time for postal delivery. For a prior-year contribution, the bank needs to receive and process the deposit before the April 15 tax filing deadline, not just have it postmarked by then.
Online
HSA Bank lets you make the same contribution directly through the Member Website.2HSA Bank. Use Your Health Savings Account Log in, link an external bank account if you haven’t already (HSA Bank verifies it with two small test deposits), initiate a transfer, and select the tax year. This route is faster and there’s no envelope to lose. If you’re contributing close to the tax deadline, it’s the safer choice.
What to Have Ready Before You Start
The form is short. Gathering the right identifiers first prevents the errors that flag a deposit for manual review.
- Your full legal name and mailing address, entered exactly as they appear on your HSA Bank account statement. Even a missing middle initial can cause a mismatch.
- Your HSA Bank account number, which is the 8- or 12-digit number from your welcome kit or from My Profile on the member site. It is not your debit card number. Getting this wrong is the most common mistake: the form processes, but the money lands in limbo.3HSA Bank. Health Savings Account Contribution Form
- Your full nine-digit Social Security number. HSA Bank uses it to file IRS Form 5498-SA reporting your annual contributions.4Internal Revenue Service. HSA, Archer MSA, or Medicare Advantage MSA Information
- A daytime phone number and email address, so HSA Bank can reach you if something doesn’t match.
- The exact dollar amount you want deposited. If you’re mailing a check, the check must match the amount on the form.
Filling Out the Three Sections
The form has three parts: accountholder information, contribution details, and your signature.3HSA Bank. Health Savings Account Contribution Form
Accountholder Information
Enter your first name, middle initial, last name, street address, city, state, and ZIP code, then your daytime phone, email, account number, and full SSN. Every field should match your account records exactly. If you’ve recently moved or changed your name and haven’t updated your profile on the member website, do that first. A contribution form isn’t the place to introduce new information.
Contribution Details
Write the dollar amount you’re depositing. Then check one box: “Current year” or “Prior year.” This single choice determines which tax year the bank reports the deposit under on Form 5498-SA.
Signature
Sign and date at the bottom. Your signature authorizes HSA Bank to deposit the funds and confirms the contribution doesn’t exceed the legal annual limit. A handwritten signature works on paper; the member portal accepts an electronic signature and walks you through it.
Choosing Current Year or Prior Year
You can make prior-year contributions only up to the federal tax filing deadline, typically April 15, with no extensions.5Internal Revenue Service. Publication 969 – Health Savings Accounts and Other Tax-Favored Health Plans If you’re submitting in March for last year, check “Prior year” and confirm the deposit amount plus everything you already put in that year stays under the prior year’s limit. Checking the wrong box creates a contribution-limit problem you’ll have to unwind later, so read this box twice before you sign.
Check Your 2026 Limit Before You Deposit
For 2026, the IRS allows up to $4,400 for self-only high-deductible health plan coverage and $8,750 for family coverage.6Internal Revenue Service. Rev. Proc. 2025-19 If you’re 55 or older by year-end, you can add another $1,000 catch-up.7Office of the Law Revision Counsel. 26 USC 223 – Health Savings Accounts These caps cover everything going into the account: your payroll deductions, employer contributions, and any manual deposit you make on this form. Before you fill out the form, check your year-to-date contributions on the HSA Bank member dashboard and add in what comes out of your paycheck and what your employer kicks in. Overshoot the cap and the IRS charges a 6% excise tax on the excess for every year it stays in the account.5Internal Revenue Service. Publication 969 – Health Savings Accounts and Other Tax-Favored Health Plans
If You Go Over the Limit
An over-contribution is fixable without paying the 6% tax, but only if you act in time. Withdraw the excess plus any earnings on it by the due date of your tax return (including extensions) for the year the excess went in.5Internal Revenue Service. Publication 969 – Health Savings Accounts and Other Tax-Favored Health Plans Report the withdrawn earnings as other income on that year’s return, but you avoid the excise tax. Miss that window and the 6% applies every year the excess sits in the account; you report and pay it on IRS Form 5329.
Rollovers Use a Different Form
If you’re moving money from a previous HSA into HSA Bank, that’s a rollover, not a contribution, and HSA Bank has a separate Rollover Request Form for it.8HSA Bank. Transfer or Rollover HSA Funds The distinction matters because rollovers don’t count against your annual contribution limit. If you use the regular contribution form for a rollover, HSA Bank will record it as a contribution and count it toward your cap.
Two rules apply. You have 60 days from receiving the distribution from your old HSA to deposit it into the new one, and you’re limited to one rollover per 12-month period.5Internal Revenue Service. Publication 969 – Health Savings Accounts and Other Tax-Favored Health Plans A trustee-to-trustee transfer, where your old custodian sends the money directly to HSA Bank, sidesteps both restrictions and is generally the cleaner path.
What to File at Tax Time
Contributions made through the form or by online transfer (outside of payroll) don’t automatically reduce your taxable income the way pre-tax payroll deductions do. You claim the deduction yourself on IRS Form 8889 with your tax return, reporting the amount you personally contributed on Line 2. Employer contributions and pre-tax payroll deductions go on Line 9 instead, because they were already excluded from your W-2 wages. Form 8889 is required in any year someone contributed to your HSA or your HSA made a distribution.9Internal Revenue Service. Instructions for Form 8889
HSA Bank sends Form 5498-SA (usually by late May of the following year) showing total contributions received. Cross-check it against your own records, and keep your contribution form or online transfer confirmation as backup. If the numbers ever disagree, that receipt is your proof of what you deposited and when.