Health Savings Account (HSA) Application

Please select your preferred Citizens National Bank (CNB) office

Applicant Information

First Name *
MI
Last Name *
Street Address *
City *
State *
Zip Code *	-
Home Phone *	- -
Email *
Social Security Number *	- -
Date of Birth *	/ /
Drivers License Number/ID Number *
Drivers License State/ID State *
Drivers License Issue Date *	/ /
Drivers License Expiration Date * Please provide copy of Drivers License	/ /
Mother's Maiden Name *
Gender *
Marital Status *
Employer *
Work Phone	- - Ext:
Are you an existing CNB Customer? *
Backup Witholding Status *	I am NOT subject to backup withholding either because I have not been notified that I am subject to backup withholding as a result of failure to report all interest or dividends, or the Internal Revenue Service ( IRS) has notified me that I am no longer subject to backup withholding. I AM subject to backup withholding either because I have been notified that I am subject to backup withholding as a result of failure to report all interest or dividends, or the Internal Revenue Service (IRS) has notified me that I am subject to backup withholding.
If you have any comments or special instructions, please enter them here. (Maximum of 200 characters)

Health Savings Account (HSA) Information

Type of HSA *
Initial Deposit Amount (if any)
Contribution Date	/ /
Your account will be opened upon receipt of the completed new account paperwork and opening deposit (if any). Opening deposits received prior to account paperwork being completed and returned to us will be held until account is opened.
Tax Year
Please indicate the tax year for which the deposit is to be credited. Deposits received between January 1st and April 15th each year may be credited to either the current or previous tax year. If you do not indicate the tax year, it will be treated as a current year contribution.
Type of Initial Deposit *

Health Savings Account (HSA) options

All HSA come with a FREE VISA debit card to be used only for qualified medical expenses. (Subject to credit approval.)

I would like to order a starter pack of 25 duplicate checks. (Check fees will be debited from your account.)

Starter checks *

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. 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 for each beneficiary classification does not equal 100 percent, any remaining percentage will be divided equally among the beneficiaries within such class. This designation revokes and supersedes all earlier beneficiary designations which may apply to this HSA.

Beneficiary 1

First Name
MI
Last Name
Date of Birth	/ /
Social Security Number	- -
Street Address
City
State
Zip Code	-
Relationship to Applicant
Beneficiary Type
Beneficiary Percentage
Total of primary beneficiary percentages need to equaly 100%. Total of contingent beneficiary percentages need to equal 100%.

Beneficiary 2

First Name
MI
Last Name
Date of Birth	/ /
Social Security Number	- -
Street Address
City
State
Zip Code	-
Relationship to Applicant
Beneficiary Type
Beneficiary Percentage
Total of primary beneficiary percentages need to equaly 100%. Total of contingent beneficiary percentages need to equal 100%.

Beneficiary 3

First Name
MI
Last Name
Date of Birth	/ /
Social Security Number	- -
Street Address
City
State
Zip Code	-
Relationship to Applicant
Beneficiary Type
Beneficiary Percentage
Total of primary beneficiary percentages need to equaly 100%. Total of contingent beneficiary percentages need to equal 100%.

Beneficiary 4

First Name
MI
Last Name
Date of Birth	/ /
Social Security Number	- -
Street Address
City
State
Zip Code	-
Relationship to Applicant
Beneficiary Type
Beneficiary Percentage
Total of primary beneficiary percentages need to equaly 100%. Total of contingent beneficiary percentages need to equal 100%.

Beneficiary 5

First Name
MI
Last Name
Date of Birth	/ /
Social Security Number	- -
Street Address
City
State
Zip Code	-
Relationship to Applicant
Beneficiary Type
Beneficiary Percentage
Total of primary beneficiary percentages need to equaly 100%. Total of contingent beneficiary percentages need to equal 100%.

Beneficiary 6

First Name
MI
Last Name
Date of Birth	/ /
Social Security Number	- -
Street Address
City
State
Zip Code	-
Relationship to Applicant
Beneficiary Type
Beneficiary Percentage
Total of primary beneficiary percentages need to equaly 100%. Total of contingent beneficiary percentages need to equal 100%.

Beneficiary 7

First Name
MI
Last Name
Date of Birth	/ /
Social Security Number	- -
Street Address
City
State
Zip Code	-
Relationship to Applicant
Beneficiary Type
Beneficiary Percentage
Total of primary beneficiary percentages need to equaly 100%. Total of contingent beneficiary percentages need to equal 100%.

Beneficiary 8

First Name
MI
Last Name
Date of Birth	/ /
Social Security Number	- -
Street Address
City
State
Zip Code	-
Relationship to Applicant
Beneficiary Type
Beneficiary Percentage
Total of primary beneficiary percentages need to equaly 100%. Total of contingent beneficiary percentages need to equal 100%.

Add Additional

Power of Attorney (POA) Information (optional)

I would like to appoint a Power of Attorney on this Health Savings Account.

Power of Attorney

POA First Name *
POA MI *
POA Last Name *
Street Address *
City *
State *
Zip Code *	-
Home Phone *	- -
Social Security Number *	- -
Date of Birth *	/ /
Please provide copy of Drivers License
This Power of Attorney shall remain in effect if I become incompetent.
Persistant POA *
I would like an additional debit card issued for use by my POA.
POA CheckCard* *
(*Note: This CheckCard will be issued in the name of the HSA Owner only.)

Important Terms of Your Health Savings Account

* All contributions made to this HSA will be assumed to be for the current tax year unless otherwise indicated. I understand that there are maximum limits on the amount I may contribute and that I am fully responsible for not exceeding these limits.

* All distributions completed by me either in person, by check, or by use of my HSA VISA Debit Card will be reported as "normal distributions". Any distributions taken for non-qualifying medical expenses will be my responsibility to report to the IRS upon filing my income tax return.

* I agree that it is my responsibility to understand the requirements that I must meet to be eligible to open an HSA. With that understanding I state that I am qualified to establish an HSA.

* CNB does not offer tax and/or legal advice concerning HSA and I agree that I have not received any such advice from CNB relating to opening this account.

* I understand that I am requesting that CNB act as the custodian for an HSA.

* I understand that my account will not be opened until I have returned the signed enrollment form, HSA application, and Checking Account Agreement.

* If I am signing up for an HSA through an employer group I allow CNB to provide the following information about my HSA to my employer: the HSA account number, which would allow the employer to initiate automatic payments and/or debits, and the status of my HSA account (open, closed). No other information will be released to the employer without my permission.

Press SUBMIT when you have completed the application. You will receive a confirmation that your application has been submitted to us. Also, you will be emailed, through DocuSign®, new account paperwork in the next 7-10 days to sign and return to us to complete the new account opening process. If you have any questions, please contact the HSA Administrator at hsa@cnbohio.com or 419-358-8060 extension 453.

Thank you for choosing Citizens National Bank for your Health Savings Account.