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Online Enrollment

Click here to download and read the custodial agreement before submitting this form.

HSA Rules and Conditions
An HSA is a trust or custodial account created exclusively for the benefit of the HSA owner, known as “Depositor” (I/You), and is generally used to pay qualified medical expenses. I understand if I am eligible, contributions can be made to my HSA by me, my employer, and/or a designated third party. The account is solely owned by me, as the Depositor, and the HSA Custodian is Blackhawk Bank, known as “Custodian/Bank.”

I acknowledge that I must complete and sign this Application, a signed copy will be retained by the Custodian/Bank for its records. I shall retain a copy of the Application and all pertinent agreements and disclosures for my records. I agree it is in my best interest to seek the guidance of a tax or legal professional before completing this form. I acknowledge that Blackhawk Bank assumes no liability for any omissions or misstatements of any laws, including federal and state tax laws.

Depositor’s Personal Information 
Federal Law requires all financial institutions to obtain, verify and record information that identifies each person who opens an account in an effort to help the government fight the funding of terrorism and/or money laundering activities. Hence, we will ask your name, street address, date of birth and other information that allow us to identify you as the Depositor. We may also ask for a copy of your driver’s license or other identifying documents. All requested information in this section must be completed.

IDENTIFICATION
 
Online Banking:
AUTHORIZED SIGNER/POWER OF ATTORNEY (POA): Optional
I, as Depositor, hereby designate the following individual to serve as an authorized signer on my Blackhawk HSA account. I understand this POA Authorization section MUST be filled in if I, as sole individual owner/Depositor of the HSA, elect to designate my spouse and/or another third party to act as an Agent, through Power of Attorney (POA) to perform any/all acts that I may perform pursuant to this Account Agreement with the Custodian/Bank, including signing in my name (electronically or otherwise), agreements and orders relating to my HSA and/or accessing the Account to withdraw or transfer funds into or out of the Account, by any means acceptable to Custodian/Bank, including internet access.
 
 
INITIAL DEPOSIT
DEPOSITOR/POA ACCOUNT OPTIONS
I understand the purchases made with either debit MasterCard or Blackhawk Bank check(s) will be reported by the Custodian/Bank as “normal distributions.” I shall not use my debit card or checks for non-qualifying or non-medical purposes. If I do, however, I shall submit an HSA withdrawal form for any non-qualifying or non-medical transactions at a cost of $10.00 per occurrence. I understand I am responsible for any IRS taxes and penalties associated with the use of HSA funds for non-qualifying purposes. By selecting the second FREE debit card and/or checks, I, the Depositor, am requesting the Custodian/Bank issue to my spouse or other authorized third party listed a separate debit MasterCard and/or to add their name to my Blackhawk HSA checks in order to facilitate access to my Health Savings Account.
DESIGNATION OF BENEFICIARY
I understand that at the time of my death, the following individual(s) or entity(ies) shall be my primary and/or contingent beneficiary(ies). If more than one primary or contingent beneficiary(ies) is/are designated and no distribution percentages are indicated, beneficiary(ies) will be deemed to own equal share percentages in the account. If my primary or contingent beneficiary(ies) die(s) before me, his/her interest and the interest of his/her heirs shall terminate completely and the percentage share of any remaining beneficiary(ies) shall be increased on a pro-rated basis. If no primary beneficiary(ies) survives me, the contingent beneficiary(ies) shall acquire the designated share of my account. If all beneficiaries die before me, 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
Percent Name of Beneficiary SSN or Taxpayer ID Date of Birth Relationship of Depositor
% Must not exceed 100%      
         
Contingent Beneficiary
Percent Name of Beneficiary SSN or Taxpayer ID Date of Birth Relationship of Depositor
% Must not exceed 100%      
EMPLOYER INFORMATION
EMPLOYER CONSENT
In the event that I am initiating a Health Savings Account (HSA) with Blackhawk Bank through my employer, I am authorizing Blackhawk Bank to give my employer my Health Savings Account number to expedite credits to my HSA. My employer may only use this information to initiate entries on my behalf and not for any other purpose. The ACH Company is required to have a signed authorization on file for each credit or debit originated. The Company shall keep the original form for a period of no less than two (2) years after the agreement is terminated. Blackhawk Bank may request an updated copy of the form from the Company any time a change is made.
ELIGIBILITY REQUIREMENTS AND SIGNATURES
Important: Please read and understand before submitting this application. I certify that:
I am NOT covered by a health plan other than a HDHP that provides any of the same benefits as the HDHP,
I am NOT entitled to benefits under Medicare,
I may NOT be claimed as a dependent on another person’s tax return,
I am responsible for determining that I am eligible for an HSA for each month I make a contribution,
All contributions I make are within the limits set forth by the tax laws,
I understand the tax consequences of any contribution, rollover contributions and distributions, and
I have not received any tax or legal advice from the Custodian, and I will seek the advice of my own tax or legal professional to ensure my compliance with related laws. I release and hold the HSA Custodian harmless against any and all claims or losses arising from my actions.
 
If this HSA is being established with a Rollover or Transfer contribution, I certify that:
The Rollover or Transfer is from another HSA or Archer Medical Savings Account (MSA).
 
TIN BACKUP WITHHOLDING CERTIFICATION
Under penalties of perjury, I certify that:
The Internal Revenue Service does not require your consent to any provision of this document other than the certifications required to avoid backup withholding.

Blackhawk Bank is hereby appointed to serve as Custodian of my Health Savings Account. I agree to be bound by the account rules and regulations applicable to the Health Savings Account established by the Application and Agreement as they may be amended from time to time. I also agree to the Bank’s Agreements, rules and regulations, and disclosures applicable to this account and any additional accounts that I establish with the Bank in the future as an individual, custodian or single trustee; this master signature card agreement governing additional accounts will remain in effect as long as I continuously maintain at least one covered account with the bank. I certify that the information provided on this application is accurate and that I understand the eligibility requirements for an HSA Account. The number provided on my application is my correct Taxpayer Identification Number (TIN), and I am a U.S. person (including a U.S. resident alien). I understand the eligibility requirements for the type of HSA deposit I am making, and I state that I do qualify to make the deposit. I have received a copy of the Application, the HSA Custodial Agreement and Disclosure Statement, Checking Terms and Conditions, Electronic Funds Transfer Disclosure, Funds Availability Policy and Financial Privacy Rights. I understand that the terms and conditions which apply to this HSA are contained in this Application, the Custodial Agreement and Disclosure Statement. I agree to be bound by those terms and conditions. Within seven (7) calendar days from the date I open this HSA, I, the Depositor, may revoke it by mailing or delivering a written notice to the Custodian of the account. (Any collected fee is non-refundable.)

I understand my account will be established, but not funded, until I have returned a signed signature card that will be mailed to my home address upon receipt of this electronic application.

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