HSA DISTRIBUTION LEDGER RECONCILIATION
Reviewer Name:
Date of Review:
Tax Year:
Account/Platform ID:

[ ] 1. AGGREGATE GROSS OUTFLOW
Total debit card settlements: $
Total ACH direct-to-provider payments: $
Total ACH owner reimbursements: $
Total paper checks cleared: $
Total Gross Outbound Flow: $

[ ] 2. IDENTIFY EXCLUSIONS
Total trustee-to-trustee transfers (Archer/HSA to HSA): $
Total employer excess contributions returned to employer: $

[ ] 3. PROCESS REVERSALS
Mistaken distributions repaid under custodian policy: $

[ ] 4. CALCULATE REPORTABLE BASE
Gross Outbound minus Exclusions minus Reversals: $

[ ] 5. EXCESS CONTRIBUTIONS & EARNINGS
Earnings on excess contributions (Box 2): $
Are Box 2 earnings included in the reportable base above? (Y/N)
Does Box 3 reflect Code 2 if Box 2 is populated? (Y/N)

[ ] 6. SPECIAL ACCOUNT CLOSURES
Patriot Act closure distributions coded correctly? (Y/N/NA)
Date of death FMV populated in Box 4? (Y/N/NA)

Final Box 1 Reconciled Amount: $