Health Savings Account (HSA) Application

Important Information About Procedures For Opening A New Account: (PATRIOT ACT)

To help the government fight the funding of terrorism and money laundering activities, Federal law requires all financial institutions to obtain, verify, and record information that identifies each person who opens an account.

What this means for you: When you open an account, we will ask you for your name, address, date of birth, and for other information that will allow us to identify you. We may also ask to see your driver's license or other identifying documents.

I wish to establish a Healthcare Savings Account (HSA) with Fowler State Bank as the custodian and me or my agent, as Plan Service Provider and direct all my contributions to be deposited into a Fowler State Bank HSA. I have established, or I am in the process of establishing, a Qualified High Deductible Health Insurance Policy as required for the HSA.

Account Holder Information

First Name *
Middle Initial
Last Name *
Social Security Number *
Date of Birth *
Driver's License Number
State Issued
Date of Issuance
Expiration Date
Street Address *
P.O. Box
City *
State *
Zip *
Phone *
Cell Phone
Work Phone
Email *
Mother's Maiden Name
Employer
Occupation

Eligibility

I am eligible for an HSA as an Employee of an Employer who is offering them

Name of Employer *
Contact Name *
Street Address *
P.O. Box
City *
State *
Zip *
Phone *

Other (self-employed, employed but responsible for health insurance coverage, retired, etc.)

HDHP Plan Coverage

Individual Plan - Insures you only Family Plan - Insures you and your family

Agreement/Signature

I certify that all information provided by me is true, correct, and complete. I authorize Fowler State Bank to make whatever inquiries about me they deem necessary and appropriate for the purpose of evaluating my credit application, including credit reports and contacting my employer. I also authorize Fowler State Bank to provide credit information about its credit experience with me to other creditors and credit reporting agencies.

Applicant Signature *
Bank Representative