Health Savings Account (HSA) Application

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 identifies 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 will also ask to see your driver's license or other identifying documents.

After your application is received and processed, we will contact you by phone or email within 7-10 business days.

Location Loan Officer/Personal Banker

How did you hear about Five Points Bank?

Friend
Family Member
Online Ad
Television/Radio Ad
Social Media
Other

Describe Other

HSA Owner Information

First Name Middle Initial Last Name Date of Birth (MM/DD/YYYY) Social Security Number Street Address City State Zip Mailing Address (if different) City State Zip Home Phone Cell Phone Business Phone E-Mail Address

Citizenship Status:

U.S. Citizen
Resident Alien
Non-Resident Alien

Country of Citizenship if Not a U.S. Citizen Driver's License/ID Number State Issue Date (MM/DD/YYYY) Expiration Date (MM/DD/YYYY) Employer Occupation

Do you, your immediate family members, or any close associates hold a public office or government position in a foreign country?

Type of Health Insurance Plan Coverage (select one):

Self-Only
Family

Contribution Information

Amount Contribution Date (MM/DD/YYYY) Tax Year

Contribution Type:

Regular (including Catch-up and contributions made through employer)
Transfer from an HSA
Rollover from an HSA
Contribution from an IRA

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 Beneficiary

First Name Middle Initial Last Name Street Address City State Zip Date of Birth (MM/DD/YYYY) Social Security Number Relationship Share (%)

 Add Another Primary Beneficiary

Contingent Beneficiary

First Name Middle Initial Last Name Street Address City State Zip Date of Birth (MM/DD/YYYY) Social Security Number Relationship Share (%)

 Add Another Contingent Beneficiary

Spousal 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.

I Am Married. I understand that if I designate a primary beneficiary other than my spouse, my spouse must consent by signing below. Please enter HSA Owner Initials here for Consent
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. Please enter HSA Owner Initials here for Consent

Authorized Signer - Optional

Would you like to designate an authorized signer to access and initiate transactions on your account?

First Name Middle Initial Last Name Date of Birth (MM/DD/YYYY) Social Security Number Address different from HSA owner Street Address City State Zip Home Phone Cell Phone Driver's License/ID Number State Issue Date (MM/DD/YYYY) Expiration Date (MM/DD/YYYY) Employer Occupation

Do you, your immediate family members, or any close associates hold a public office or government position in a foreign country?

Account Selections (mark all that apply):

I would like to order free HSA checks
I would like to order a free HSA debit card
I would like to order a free HSA debit card for my authorized signer
I would like to set up online banking
I would like E-Statements

Estimated Account Activity

What is the amount of your average estimated Monthly Cash Deposit? What is the source of the cash?

Do you plan to initiate Domestic and/or International wire transfers?

If yes, the estimated average monthly amount of the wire?

Do you plan to receive Domestic and/or International wire transfers?

If yes, the estimated average monthly amount of the wire?

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.

Signature of HSA Owner Date (MM/DD/YYYY)

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

Health Savings Account (HSA) Application

How did you hear about Five Points Bank?

HSA Owner Information

Citizenship Status:

Do you, your immediate family members, or any close associates hold a public office or government position in a foreign country?

Type of Health Insurance Plan Coverage (select one):

Contribution Information

Contribution Type:

Designation of Beneficiary

Primary Beneficiary

Contingent Beneficiary

Spousal Consent

Authorized Signer - Optional

Do you, your immediate family members, or any close associates hold a public office or government position in a foreign country?

Account Selections (mark all that apply):

Estimated Account Activity

Do you plan to initiate Domestic and/or International wire transfers?

Do you plan to receive Domestic and/or International wire transfers?

Signature of HSA Owner

Trust

Investments