FNB Ames Health Savings Account (HSA) Form

Health Savings Account (HSA) Form

Please enter your personal information below:

STEP 1: Select an Account

Select a Health Savings Account (HSA)

HSA - family
HSA - Self-only

IMPORTANT INFORMATION ABOUT PROCEDURES FOR OPENING A NEW ACCOUNT: To help the government fight the funding of terrorism and money laundering activities, Federal law requires all financial institutions to obtain, verify and record information that identifies each person who opens an account. What this means for you: When you open an account, we will ask for your name, address, date of birth and other information that will allow us to identify you. We may also ask to see your driver's license or other identifying documents.

STEP 2: Tell Us About Yourself

Primary Account Owner

Name (First M. Last)
Date of Birth (mm/dd/yyyy)
SSN
Home Phone Number	( ) -
Work Phone Number	( ) -
Cell Phone Number	( ) -
Address	(No P.O. Boxes accepted)
City, State Zip-Plus4	, -
Email
Mother's Maiden Name
Driver's License Number		State
Expiration		Date Issued
Current Employer

STEP 3: Describe Contribution Information

Tax year (mm/dd/yyyy)

Contribution Type

Regular
Rollover from a HSA
Transfer from a HSA
Contribution from an IRA
Catch-Up (age 55 or older and not enrolled in Medicare)
Rollover from an Archer Medical Savings Account
Transfer from an Archer Medical Savings Account
Rollover from a Health Reimbursement Arrangement/Health Flexible Spending Plan

STEP 4: Designation of Beneficiaries

At the time of my death, the primary beneficiaries named below will receive my HSA assets. If all of my primary beneficiaries die before me, the contingent beneficiaries name below will receive my HSA assets. In the event a beneficiary dies before me, such beneficiary's share will be reallocated on a pro-rata basis to the other beneficiaries that share the deceased beneficiary's classification as a primary or contingent beneficiary. If all of the beneficiaries die before me, my HSA assets will be paid to my estate. If no percentages are assigned to beneficiaries, the beneficiaries will share equally. If the percentage total of each beneficiary does not equal 100 percent, any remaining percentage will be divided equally among the beneficiaries within such class. This designation revokes and supercedes all earlier beneficiary designations which may apply to this HSA.

A. Primary Beneficiary

PERCENTAGE	NAME OF BENEFICIARY	SSN OR TAXPAYER ID NUMBER	RELATIONSHIP TO HSA OWNER
%
%
%
Total 100%

B. Contingent Beneficiary

PERCENTAGE	NAME OF BENEFICIARY	SSN OR TAXPAYER ID NUMBER	RELATIONSHIP TO HSA OWNER
%
%
%
Total 100%

Spousal Consent

Community or marital property state laws may require consent for a nonspouse beneficiary designation. The laws of the state in which the financial organization is domiciled, the HSA owner resides, the trust is located, the spouse resides, or this transaction is consummated should be review to determine if such a requirement exists. Spousal consent for the beneficiary designation may also be required by financial organization policy.

I am married. I understand that if I designate a primary beneficiary other than my spouse, my spouse must consent by signing below.
I am not married. I understand that if I marry in the future, I must complete a new Designation of Beneficiary form, which includes the spousal consent documentation.

I am the spouse of the HSA owner. Because of the significant consequence associated with giving up my interest in the HSA, the custodian has not provided me with legal or tax advice, but has advised me to seek tax or legal advice. I acknowledge that I have received a fair and reasonable disclosure of the HSA owner's assets, I hereby give to the HSA owner such interest in the assets held in this HSA and consent to the beneficiary designation set forth in Section 3 of this form.

Signature of Spouse

X _______________________________

Date: _______________

STEP 5: Learn About Account Access

Internet Banking Would you like to access your accounts online with Free Internet Banking?
Yes	No

Debit Cards
Would you like to order a Debit Card to pay for medical expenses?*

Debit Card

No Debit Card at this time.

Name on Card 1

It is certified that the above information is complete and true, and is given to induce you to issue said Card. I authorize you to make whatever credit and/or investigative inquiries deemed necessary in connection with this application and to exchange with others regarding my Card transactions. I understand that this Card is not a Credit Card, and that no commitment to extend credit to me will be made by your issuance of the Card requested. I hereby authorize First National Bank to issue a Debit Card.

Debit Card Orders
There is no annual fee for this card. If my card is lost or destroyed, I understand the charge for a replacement card is $8.00.

STEP 6: Fund Your Account

Fund Your Account
Do not put comma(,) when you enter a dollar amount in the text fields below
i.e "1000"

Initial Deposit

Initial Deposit Types

Transfer funds from an existing FNB Account.
Account Number

Check
Send to:
First National Bank
Attn. Lauri Werner
405 5th Street
Ames, Iowa 50010

ACH
I authorize you to initiate an electronic withdrawal from my current bank to fund my new account.

Current Bank:

Name and Address
Routing Number
Account Number

STEP 7: Verify Information

Social Security Number(s) The Social Security Number(s) shown above is my correct SSN.

If this HSA is being established with a regular contribution, I certify that I am covered by a qualified high deductible health plan (HDHP), and that I am not covered by a health plan other than a HDHP that provides the same benefits as a HDHP. I certify that the information provided by me on this application is accurate. I understand that once this application is received by the Bank, I will receive a copy of the IRS Form 5305-C, Health Savings Custodial Account, the Disclosure Statement, and amendments thereto. I assume sole responsibility for all consequences relating to my actions concerning this HSA. I have not received any tax or legal advice from the custodian, and I will seek the advice of my own tax or legal professional to ensure my compliance with related laws. I release and agree to hold the HSA custodian harmless against any and all claims or losses arising from my actions.

Signature of HSA Owner

X ____________________________________

Date: _______________

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