Hsa Enrollment Form (Page 3 of 3) in pdf

Hsa Enrollment Form Page 3

Dependent Information

If you have family coverage, please complete the following information regarding dependents that are covered by your health plan.

Last Name

First Name

Middle Initial

Social Security Number

Date of Birth

Street Address

City State

Zip Code

Dependent’s Relationship to HSA Account Holder

Order Debit Card:

Yes

Last Name

First Name

Middle Initial

Social Security Number

Date of Birth

Street Address

City State

Zip Code

Dependent’s Relationship to HSA Account Holder

Order Debit Card:

Yes

Last Name

First Name

Middle Initial

Social Security Number

Date of Birth

Street Address

City State

Zip Code

Dependent’s Relationship to HSA Account Holder

Order Debit Card:

Yes

IMPORTANT: Please read before Signing

I understand the eligibility requirements for the type of HSA deposits that I will be making and I state that I qualify to make deposits in my Fifth Third HSA Checking

Account. I understand that the terms and conditions, which apply to the Fifth Third HSA Checking Account, are contained in the Disclosure Statement, Fifth Third

Bank Rules and Regulations and HSA Custodial Agreement. I understand electronic copies of these documents can be located online within my HSA.

I understand that I assume sole responsibility for how this individual (“Authorized User”) utilizes my HSA Account. By signing below the Authorized User

acknowledges and agrees that they are able to act on behalf of the HSA account holder only. Access to other accounts of the HSA account holder will not be

granted. Signature of Authorized User is required on the last page of this application.

I ASSUME COMPLETE RESPONSIBILITY FOR:

Determining that I am eligible for an HSA each year I make any contributions to my HSA.

Ensuring that all contributions that I make are within the limits set forth by the tax laws.

The tax consequences of any contributions (including rollover contributions) and distributions.

Signature of HSA Account Holder

Date

Signature of Authorized User (if entered on first page)

Date

04/2010