Wells Fargo Health Saving Account Account Authorization Form

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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
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
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
Print: ________________________________________________________________________
First Name
Middle Initial
Last Name
Print: ________________________________________________________________________________________
Residential Street Address (No P.O. Box)
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
Please fill out, sign and return this form to your Employer. Do not send this form to Wells Fargo Health Benefit Services.


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