HSA Set-Up

Health Savings Account (HSA) Set-up at Interra Credit Union Account Holder Information Name (First, Middle, Last) Social Security Number Birthdate (MM/DD/YYYY) Mother’s Maiden Name Drivers License Number State Issue Date Expiration Date Street Address City State Zip Code Mailing Address (if dierent) Home Phone Number Cell Phone Number E-mail Address ( ) ( ) Employer Occupation Type of Coverage Single Family Primary Beneficiary(ies) - Column MUST total 100% % Name Mailing Address Relationship Birthdate Social Security # Contingent Beneficiary(ies) - Column MUST total 100% % Name Mailing Address Relationship Birthdate Social Security # I/we consent that the Credit Union may verify my/our eligibility for any account(s)/service(s) now and in the future. In addition, I/we authorize the Credit Union to make inquiry to determine my/our employment history and to obtain information concerning any accounts with our institutions and my/our credit history, including any credit reports. I/we specifically consent that the Credit Union may report information concerning my/our account(s)/service(s) to others; and that the Credit Union may provide the reasons if I/we are determined to be ineligible for any service(s) or to be an authorized person/user to the other applicants. Signature Date Please return this form as soon as possible to: • Fax to Interra at 574.975.3231 Attn: HSA • Send to Interra at P.O. Box 727 - Goshen, IN 46527 Attn: HSA • Due to personal information on the form, please do NOT scan and e-mail. If you have any questions, please call Interra at 574.534.2506 or 888.432.2848 01/24