Account Holder Instructions - BenefitWallet - bny mellon pension 1099

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• (1) Voya bny mellon 401k
• (2) Bny mellon disbursement pension
• (3) Bny mellon pension payments
• (4) Bny mellon 1099 r forms

Request for Copy of HSA Tax Form
Account Holder Instructions
To request copies of HSA tax forms for your BenefitWallet? Health Savings Account (HSA), complete this form and send the
ORIGINAL form to The Bank of New York Mellon (BNY Mellon) at the address below. BNY Mellon will charge your account a fee
of $5.00 per tax form, or as stated on your rate and fee schedule, in accordance with the Health Savings Account Fee and Rate
schedule. Please allow 20 business days to process your request.
Send this completed and signed form (not a copy) to BNY Mellon at:
U.S. Mail: Courier/Overnight:
BenefitWallet SEC BenefitWallet
P.O. Box 18030 1434 Crossways Blvd.
Norfolk, VA 23501-1880 Attn: East Wing
Chesapeake, VA 23320
* Note: Tax forms are available online at www.mybenefitwallet.com.
BenefitWallet HSA Account Request for Copy of HSA Tax Form
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Request for Copy of HSA Tax Form
Name: _______________________________________________________________________________________
(as currently displayed on account)
HSA Checking Account Number: 9500
Note: Your account number can be found in the upper right corner of your BenefitWallet Welcome Kit cover letter, on the account
holder statements, as well as on the member portal and your BenefitWallet checks and deposit slips.
I am requesting a copy of the tax form(s) for the year(s) indicated below. This information should be mailed to the address
on record. If your address has changed, please submit a Change of Address Form with this request.
Specify Tax Form(s) for which a Tax Form Copy is to be provided:
1099 SA Distributions from an HSA Account 5498 SA Contributions to an HSA Account
Specify year(s) applicable to the tax form(s) indicated above. If the form request includes more than one year, please complete
one form for each year.
2004 2005 2006 2007 2008 2009 2010 2011
2012* 2013* 2014* 2015* 2016* 2017* 2018*
* 2012 through 2018 tax forms are downloadable online. Tax forms are available online at www.mybenefitwallet.com.
Note: A fee of $5.00 for each tax form requested, or as stated on your rate and fee schedule, will be assessed and deducted from
your HSA account.
By completing, signing and submitting this form for processing, I authorize the deduction of all applicable fees from my account
and the release of the requested form(s).
_____________________________________________________________________________________________________
Account Holder's signature is required.
Address
City, State, Zip
Please return the completed form via U.S. Mail or Courier/Overnight as shown below:
U.S. Mail: Courier/Overnight:
BenefitWallet SEC BenefitWallet
P.O. Box 18030 1434 Crossways Blvd.
Norfolk, VA 23501-1880 Attn: East Wing
Chesapeake, VA 23320
For Internal use only:
Signature Verified by: Date:
Tax Form 1099 SA Copy Prepared by: Date:
Tax Form 5498 SA Copy Prepared by: Date:
? 2020 Conduent Inc. All rights reserved. Conduent, Conduent Agile Star and BenefitWallet? are trademarks of Conduent Inc. and/or its subsidiaries in the United States and/or other countries. HSA-M-3035-0520
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What are BNY Mellon’s agreements on Form 10K? Pursuant to the rules and regulations of the SEC, BNY Mellon has filed certain agreements as exhibits to this Form 10-K. These agreements may contain representations and warranties by the parties to such agreements.

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