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. The undersigned further authorizes the financial institution to verify credit and employment history and/or have a credit reporting agency prepare a credit report on the undersigned, as individuals, for the purpose of verification of your personal information.