Health Savings Account Application

Health Savings Account Application - Personal Services

  • Account Owner Identification Information (required by law)

    It is important that we receive all of the following information to expedite the opening of your new HSA account, and to ensure that we provide you with exactly which services you desire. Thank you for the opportunity to serve your HSA needs!
  • Patriot Act Disclosure

    Federal law requires all financial institutions to obtain, verify and record information that identifies each person who opens an account. We must ask you for certain identifying information contained herein, and because most HSA accounts are not opened in person, we must verify your identity. By checking below you authorize 1) Heritage Bank to obtain a credit bureau report for that purpose and 2) certify that all information is correct. Thank you.
  • Eligibility Information

    According to the IRS, you are eligible to establish this HSA only if you meet the following eligibility requirements: (1) you are covered by a high deductible health plan (HDHP); (2) you are not covered by a non-HDHP; (3) you are not able to be claimed as a dependent by another taxpayer; and (4) you are not age 65.
  • Please provide name of your employer.
  • Designation of Inheriting Beneficiary

    Section 1.5 of Article VII of the Health Savings Custodial Account Agreement contains an important discussion of your right to name primary and contingent beneficiary(ies). Your designation will revoke all prior HSA beneficiary designations with respect to the referenced HSA account. In the event of your death you hereby direct that any balance in your HSA shall be paid to the following designated beneficiary or beneficiaries. If any primary or contingent beneficiary dies before you, then you wish to have the following result:
    If you do not select an option above, then you are deemed to have elected the “pro rata” selection.
  • Inheriting Beneficiary(ies)

    *If you wish to designate more than four primary or contingent beneficiaries, please provide a complete listing on a separate piece of paper along with your completed application.
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  • Convenient Account Access

  • Approval

    You have requested that Heritage Bank establish a Health Savings Account (HSA) for you. You certify that you are eligible for an HSA contribution and your tax identification number (social security number) and other information are correct. In the event that this is a rollover contribution, you hereby irrevocably elect to treat this contribution as a rollover contribution. The rules and conditions governing this HSA form are contained in this application and the plan agreement. You acknowledge that the Custodian will furnish you with a copy of the application, and the HSA Plan and Disclosure Statement. You expressly acknowledge that you are responsible to determine your eligibility for this HSA and the permissibility of your contribution amount.