Personal Information - Wells Fargo Health Account Manager

Individual Application for a Health Savings Account (HSA)
Important: Please ensure that you have completed both pages before signing and dating this form .
Personal Information *required field
First Name*
Middle Name
Last Name*
Street Address* (required; may not be a P.O. Box)
City*
State*
Zip*
Mailing Address
City*
State*
Zip*
Alternate Phone XXX-XXX-XXXX
Phone* XXX-XXX-XXXX
Email
Date of Birth*
(MM/DD/YYYY)
Country of Citizenship*
Residency Status*
US Citizen
Resident Alien
Health Insurance Carrier*
Opening Deposit
Social Security Number* XXX-XX-XXXX
Non-Permanent/Non-Resident Alien
Coverage Type*
Single
Family
$100.00 Minimum Opening Deposit Required
Tax Year: ____________________ Tax year to which contribution applies. All initial funds will be deposited in the year they are received unless otherwise indicated.
Previous tax year contributions are accepted through the IRS tax return filing deadline for that year.
Please identify the source of your opening deposit funds.
Personal / Employer — Check made payable to Wells Fargo HBS enclosed for $_________________________
Rollover from Archer MSA
Transfer from Archer MSA
Rollover from HSA
Transfer from HSA
Check made payable to Wells Fargo HBS enclosed for $_________________________.
For more information about the difference between a rollover and a transfer, please visit wellsfargo.com/hsa.
Transfer from IRA, HSA or Archer MSA – If you would like Wells Fargo to request funds from your Trustee/Custodian, please complete the Rollover/Transfer to a
Health Savings Account (HSA) form available at wellsfargo.com/hsa.
Disclosures
HSA Custodial Agreement. The terms of the HSA are set forth in the HSA Custodial Agreement that is included in the welcome packet, which is sent once the account is
opened. You may also obtain a copy of the agreement by calling Customer Service Center at 1-866-884-7374.
Establish HSA. I hereby request that Wells Fargo Health Benefit Services (HBS) establish an HSA in my name. I certify that I am eligible to contribute to an HSA under
Internal Revenue Code §223. I acknowledge that my HSA will be established pursuant to the HSA Custodial Agreement. I understand that I may revoke this agreement
within seven days of receiving the HSA Custodial Agreement in the welcome packet. I certify that HBS is authorized to act in accordance with any future documents bearing my signature. I further certify that the number shown on this form is my correct taxpayer identification number (TIN) (or I am waiting for a number to be issued to me).
FDIC Insured Account/Investment Fund Elections. I understand that uninvested funds in my HSA will be held in a Federal Deposit Insurance Corporation (“FDIC”)
insured interest-bearing deposit account (“Deposit Account”) pursuant to the HSA Custodial Agreement. Once I build a minimum balance in the Deposit Account, I will
have the option to invest additional HSA contributions in mutual funds. I understand that I will receive a prospectus for the mutual funds in which my HSA funds are
invested. I understand that investments in any such mutual fund are not obligations of, or endorsed or guaranteed by, Wells Fargo Bank, N.A. or its affiliates and are not
insured by the FDIC. Wells Fargo Funds Management, LLC serves as investment advisor and Wells Fargo Bank, N.A., serves as custodian for the Wells Fargo Advantage
Funds. I also understand that Wells Fargo Bank, N.A. will be paid, and certain of its affiliates may be paid, fees for services to the Wells Fargo Advantage Funds and that
those fees are described in the prospectus.
The USA PATRIOT ACT OF 2001 requires financial institutions to obtain, verify and record information to confirm the identity of each individual that opens an account.
What this means for you: Before you open an account, we will ask for your name, address, date of birth (if you are an individual), taxpayer identification number (TIN), and
other information that will allow us to identify you.
Monthly Service Fee. A monthly service fee will automatically be deducted from your HSA unless your employer or insurance carrier is paying the fee on your behalf.
The standard fee is $4.25 unless otherwise specified by your employer or insurance carrier. Information on the monthly service fee and other fees will be included in your
Welcome Packet.
By signing below, I am verifying that I have read and agree to the above disclosures. I also authorize Wells Fargo to make any inquiries that it considers appropriate to determine if it should open and maintain my HSA. This may include ordering my credit (or other) report (e.g., information from any motor vehicle department or other state agency).
Signature
Please Print and Sign
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Date (MM/DD/YYYY)
HSA Information
Beneficiary Designation. Once your HSA is established with Wells Fargo, you may designate a beneficiary by completing a Designation/Change of Beneficiary form.
You can obtain this form by signing on to the Wells Fargo Health Account Managersm portal at wellsfargo.com/hsa or by contacting the Customer Service Center at
1-866-884-7374. If you choose not to designate a beneficiary, any beneficiary distribution will be handled per the HSA Custodial Agreement.
Referral Source. Please let us know how you were referred to Wells Fargo Health Benefit Services.
Carrier – Carrier Name:
Web – Web site URL:
Broker/Agent – Broker/Agent Name:
Please mail this completed and signed form and your check or money order to:
Wells Fargo Health Benefit Services, P.O. Box 45600, Salt Lake City, UT 84145-0600
Questions? Please contact our Customer Service Center at 1-866-884-7374.
Web site: wellsfargo.com/hsa
Funds may not be available for immediate withdrawal.
wellsfargo.com/com
©2011 Health Benefit Services, A Division of Wells Fargo Bank,, N.A.
All rights reserved. Member FDIC.
HSA-IEF-HSAT: OF-340-051 6/11
For internal use only: Processing code NC
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