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Health Savings Account (HSA) Application Form

Instructions: Complete the fields below. Submit online or print the form from your internet browser, mail or fax your application to: Five Points Bank, P.O. Box 1507, Grand Island, NE 68802, Fax: 308-384-9783. For assistance, call (308)384-5350, Monday- Friday, 8 a.m. - 5 p.m., CT.

To help the government fight the funding of terrorism and money laundering activities, federal law requires that all financial institutions obtain, verify, and record information that identities each person who opens an account. What this means to you: when you open an account, we will need you and your authorized signer to provide name, street address, date of birth and other information that will enable us to identify you and your authorized signer. We may also ask to see your driver's license or other identifying documents.

After your application is received and processed, you will receive a packet by mail in 7-10 business days. Your debit card(s) and/or checks will arrive by mail in a separate mailing about 10-14 business days after your application is processed.

HSA Owner Information

Citizenship Status:

Type of Health Insurance Plan Coverage (select one):

Contribution Information

Contribution Type:

Designation of Beneficiary

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 named 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. A designation of a beneficiary's primary or contingent classification is generally made by entering a percentage in one of the two columns to the left of the name. In the event a beneficiary is named as both a primary and contingent beneficiary, or if a beneficiary is not assigned to a beneficiary classification, such beneficiary shall be a primary beneficiary. If no percentages are assigned to beneficiaries, or if the percentage total for any beneficiary classification exceeds 100 percent, the beneficiaries in that beneficiary classification will share equally. If the percentage total for each beneficiary classification is less than 100 percent, any remaining percentage will be divided equally among the beneficiaries within such class. If all of the beneficiaries die before me, or if none are designated, my HSA assets will be paid to my estate. This designation revokes and supercedes all earlier beneficiary designations which may apply to this HSA.

Primary

Add Another Primary Beneficiary

Contingent

Add Another Contingent Beneficiary

Consent

Community or marital property state laws may require spousal consent for a non-spouse 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 reviewed to determine if such a requirement exists. Spousal consent for the beneficiary designation may also be required by financial organization policy.

Type of Health Insurance Plan Coverage (select one):

Authorized Signer - Optional

If you would like to designate an authorized signer to access and initiate transactions on your account, complete the following fields.

Account Selections (mark all that apply):

Signature of HSA Owner

By signing below, I certify that:

  • I am or will be, covered by a qualified high deductible health plan {HDHP), and I am not enrolled in Medicare or covered under other health insurance that is not compatible with an HSA, and I may not be claimed as a dependent on another person's tax return (excluding spouses per the Internal Revenue Service {IRS).
  • Five Points Bank is hereby appointed to serve as custodian of my Health Savings Account.
  • I understand that the custodian cannot provide, and has not provided, me with tax or legal advice. I have been advised to seek the guidance of a tax or legal professional.

or  Sign the application and mail or fax to the address or fax number listed above.

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