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Street Address City State Zip Mailing Address (if different from above) City State Zip Home Work Phone Phone Employer Occupation ATTACH COPY OF DRIVER S LICENSE - REQUIRED State E-Mail Required Driver s License (copy- required) Issued.

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Before you purchase an item, you should check with your HSA administrator to determine if your expense is HSA eligible with a LOMN.

To be an eligible individual and qualify for an HSA, the taxpayer must meet the following requirements: Be covered by a high-deductible health plan (HDHP) on the first day of the month. Not be covered by other health insurance (see Publication 969 for exceptions)

Individuals Who Qualify for an HSA Be covered by a high-deductible health plan (HDHP) on the first day of the month. Not be covered by other health insurance (see Publication 969 for exceptions) Not be enrolled in Medicare (the individual can be HSA-eligible for the months before being covered by Medicare)

You're not eligible for an HSA if you are: Covered by another health insurance plan, such as a spouse's plan, that is not a qualified HDHP. Claimed as a dependent on another person's tax return.

Your HSA Bank Health Benefits Debit Card provides access to your HSA funds at point of sale with signature or PIN and at ATMs for withdrawals.

Gym memberships. While some companies and private insurers may offer discounts on gym memberships, you generally can't use your FSA or HSA account to pay for gym or health club memberships.

Hold on to any insurance carrier's Explanation of Benefits (EOB) statement that documents your expenses for services covered under your HSA-eligible health plan. Keep receipts for all other items purchased with your HSA, for example, vision and dental services.

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© Copyright 1997-2025
airSlate Legal Forms, Inc.
3720 Flowood Dr, Flowood, Mississippi 39232
Form Packages
Adoption
Bankruptcy
Contractors
Divorce
Home Sales
Employment
Identity Theft
Incorporation
Landlord Tenant
Living Trust
Name Change
Personal Planning
Small Business
Wills & Estates
Packages A-Z
Form Categories
Affidavits
Bankruptcy
Bill of Sale
Corporate - LLC
Divorce
Employment
Identity Theft
Internet Technology
Landlord Tenant
Living Wills
Name Change
Power of Attorney
Real Estate
Small Estates
Wills
All Forms
Forms A-Z
Form Library
Customer Service
Terms of Service
DMCA Policy
About Us
Blog
Affiliates
Contact Us
Privacy Notice
Delete My Account
Site Map
All Forms
Search all Forms
Industries
Forms in Spanish
Localized Forms
Legal Guides
Real Estate Handbook
All Guides
Prepared for You
Notarize
Incorporation services
Our Customers
For Consumers
For Small Business
For Attorneys
Our Sites
US Legal Forms
USLegal
FormsPass
pdfFiller
signNow
airSlate workflows
DocHub
Instapage
Social Media
Call us now toll free:
1-877-389-0141
As seen in:
  • USA Today logo picture
  • CBC News logo picture
  • LA Times logo picture
  • The Washington Post logo picture
  • AP logo picture
  • Forbes logo picture
© Copyright 1997-2025
airSlate Legal Forms, Inc.
3720 Flowood Dr, Flowood, Mississippi 39232