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Filling out the HSA Bank Application & Eligibility Form is essential for individuals seeking to establish a Health Savings Account. This guide provides step-by-step instructions to help users complete the form accurately and efficiently.

Follow the steps to successfully complete the HSA Bank Application & Eligibility Form.

1. Click the ‘Get Form’ button to acquire the HSA Bank Application & Eligibility Form and open it in an accessible editor.
2. Fill out the personal information section. Enter your Social Security number, birth date, first name, middle initial, last name, street address, city, state, zip code, and preferred mailing method. Additionally, provide your contact numbers and form of identification.
3. Indicate the type of initial deposit you are making and the source of those funds. Check the appropriate box based on whether it is a regular deposit, rollover, employer, or trustee transfer, and include the amounts.
4. Select the HSA account options. Indicate if you want to order checks or a debit card. Review the stipulations regarding the use of these tools for normal distributions only.
5. Complete the eligibility requirements section. Certify that you meet the necessary criteria to establish a Health Savings Account and provide the effective date of your High Deductible Health Plan.
6. If applicable, enter the required employer information. This includes the employer's name, contact details, and type of business.
7. Designate any authorized signers or powers of attorney by entering their information and signing in the appropriate fields.
8. Review all information entered for accuracy, sign the application, and date it. Ensure that a witness's signature is provided where required.
9. Once completed, save your changes, download the form, and print or share it as necessary.

Ensure your Health Savings Account application is complete by following these steps online!