Fillable Wells Fargo Health Saving Account Account Authorization Form printable pdf download

Addendum C

Wells Fargo Health Saving Account

Account Authorization Form

Enrollment Election

I want to establish a Health Savings Account (“HSA”) at Wells Fargo Bank, N.A. (“Wells Fargo”). I certify that I am eligible to contribute to

an HSA under Internal Revenue Code Section 223. I understand that I may access the agreements governing my HSA via the Wells Fargo

Health Account Manager

web portal online at or by calling 866-884-7374. I further understand that a copy of the

agreements governing my HSA will be sent to me in a “welcome packet” after my HSA is opened and that I will have seven (7) business days to

revoke my HSA after the welcome packet is sent.

Appointment of Employer as Special Agent for Account Opening Purposes

By signing in below, I appoint ___________________________ (“Employer”) as my special agent for purposes of opening a Wells Fargo

HSA.

As my special agent, Employer will receive a notice from Wells Fargo on my behalf, which explains that, consistent with its efforts to help

the government of the United States fight money laundering activities and terrorism funding, Wells Fargo obtains, verifies and records

information to identify each individual who opens a Wells Fargo HSA. I hereby provide the Identifying Information listed below to

Employer and authorize Employer to forward this information to Wells Fargo on my behalf in furtherance of my establishing a Wells Fargo

HSA.

I agree that Employer will be my special agent unless and until the earlier of the following three events occurs: (i) I submit written notice to

Employer that I intend to terminate this appointment, and Employer has a reasonable period of time to act on such notice; (ii) I receive my

HSA “welcome packet” from Wells Fargo; or (iii) I receive a notice from Wells Fargo that my application for an HSA has been declined.

Identifying Information: Employee Name, Address, Date of Birth, Social Security Number, Phone Number, Country of

Citizenship

Print: ________________________________________________________________________

First Name

Middle Initial

Last Name

Print: ________________________________________________________________________________________

Residential Street Address (No P.O. Box)

City

State

Zip Code

____/______/___________

_____/____/__________

_____________________

Date of Birth (mm/dd/yyyy)

Social Security Number

Home/Cell Phone Number

____________________________________

_____________________

Country of Citizenship

Residency Status

(U.S. Citizen or Permanent/Resident Alien or Non-Permanent/Non-Resident Alien

Signature of Employee

By signing below, I agree to the above. 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).

____________________________________________

____________

Employee Signature

Date

Please fill out, sign and return this form to your Employer. Do not send this form to Wells Fargo Health Benefit Services.

ASA-HSAT-05/18/10

Wells Fargo Health Saving Account Account Authorization Form

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