Form Wp 11371 - Member Contribution Form

Member Contribution Form

Personal information

Your name: _______________________________________________________________________________________

First

Last

Middle initial

Your address: _____________________________________________________________________________________

Street

City

State

ZIP

Phone: (______) _________________________________ Email _____________________________________________

Account holder Social Security number: ______________________________________________________________

Contributions

Contribution tax year: _______________________

Contributions for the prior year are accepted until April 15th of the current year. Funds will be applied to the tax year of the date

on the attached check if no year is indicated.

How would you like to deposit funds into your HSA?

Option 1: Check

Option 2: One time electronic funds

Option 3: Recurring monthly electronic

transfer

funds transfer

Include a check (payable to

Fax this form and a voided check to:

Fax this form and a voided check to:

HealthEquity, Inc.) with this

801-727-1005

801-727-1005

contribution form.

Amount of deposit: $ _____________________

Monthly amount of deposit: $ _____________

Mail to:

Financial institution: ______________________

Date of first transfer: _____________________

CDH Administrator

City/State: ______________________________

Financial institution: ______________________

15 West Scenic Pointe Drive,

Account type:

Checking

Savings

City/State: ______________________________

Suite 400

Draper, UT 84020

Routing number: _________________________

Account type:

Checking

Savings

Account number: ________________________

Routing number: _________________________

Account number: ________________________

Contributions can also be made online through your Personal Desktop. Just log in to Member Secured Services at

and click the HealthyBlue HSA/HRA/FSA tab.

Authorization

I hereby authorize the deposit of the amount stated above into my health savings account. I understand the eligibility

requirements for the type of deposit I am making and I state that I do qualify to make the deposit.

I assume complete responsibility for:

1. Determining that I am eligible for an HSA each year I make a contribution.

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

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

____________________________________________________ _________________________

Account holder signature

Date

HealthEquity, Inc. is an independent company partnering with Blue Cross Blue Shield of Michigan to provide health care spending account administration services. An independent and

FDIC-insured bank holds the health savings account dollars.

Blue Cross Blue Shield of Michigan is a nonprofit corporation and independent licensee of the Blue Cross and Blue Shield Association.

WP 11371 DEC 12

R011421