Direct Transfer Form

Use this form to transfer your existing HSA balances to your Gulf Coast Educators HSA.

Last three digits of your member/account number*
Name*
First Last
Email*
Phone*
IRA or HSA Direct Transfer*
- IRA
- HSA
Name of current institution where account is held*
Mailing address of current institution
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Account number of account at current institution*
Would you like to transfer the full amount?*
- Yes
- No
Signature