INCOMING HSA FUNDS REVIEW CHECKLIST
Account Holder ID:
Receiving Account Number:
Date of Receipt:
Amount Received:

1. SOURCE IDENTIFICATION
[ ] Received directly from external financial institution
[ ] Received directly from account holder (personal check / ACH)
Originating Institution Name:
Originating Account Type (if provided): [ ] HSA  [ ] IRA  [ ] MSA  [ ] Unknown

2. TRANSACTION CLASSIFICATION
[ ] Direct HSA-to-HSA Trustee Transfer (Payable to custodian FBO account holder)
[ ] Documented qualified IRA-to-HSA funding distribution under the institution's intake process
[ ] Participant Rollover (Participant took constructive receipt, 60-day rule applies)
[ ] Standard / Payroll Contribution

3. LEDGER & FORM 5498-SA ROUTING
[ ] Direct HSA Transfer -> Exclude from Box 2 and Box 4
[ ] Qualified IRA funding distribution -> Route to Box 2 after classification review
[ ] Participant Rollover -> Route to Box 4

4. EXCEPTION HANDLING
[ ] Deposit documentation is missing source designation
[ ] Account holder clarification requested (Date: _________ )
[ ] Hold placed on tax reporting flag until resolved

Reviewer Initial: ______ Date: ______
System entry confirmed: [ ] Yes [ ] No