MISTAKEN DISTRIBUTION INTAKE AND REPORTING CONTROL
Account Holder Name:
Account Number:
Awareness year / applicable repayment deadline / source:
Original Distribution Date:
Original Distribution Amount: $
Amount Claimed as Mistaken: $

BENEFICIARY ATTESTATION
[ ] Beneficiary statement received confirming a mistake of fact due to reasonable cause.
[ ] Beneficiary signed and dated the statement.
[ ] Date of statement intake: __/__/____

SYSTEM PROCESSING
[ ] Funds received and matched to the stated mistaken amount.
[ ] Deposit routed using the designated exception code (not a standard contribution).
[ ] Verified transaction will NOT aggregate into Form 5498-SA Box 2.

TAX REPORTING ADJUSTMENT
[ ] Form 1099-SA Status: ( ) Pending Initial File  ( ) Already Filed
[ ] If Pending: System flag added to reduce Form 1099-SA Box 1 by the returned amount.
[ ] If Filed: Correction workflow initiated to reduce Box 1 and transmit to IRS.
[ ] Corrected statement furnished to recipient (if applicable).

AUTHORIZATION
Operations Reviewer:
Date Completed:
Exception/Audit Notes: