CONTRIBUTION AND INVESTMENT SELECTION - Elements …

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Page 1 of 23107 / 2614H (Rev. 5/2012) 2012 Ascensus, AND INVESTMENT SELECTIONPART 1. HSA OWNERName (First/MI/Last)_________________________ _________________Social Security Number ________________________________________ Date of Birth ____________________ Phone ______________________Email Address_________________________________ _______________Account Number__________________________________ Suffix______PART 2. HSA TRUSTEE OR CUSTODIANTo be completed by the HSA trustee or custodianName ________________________________________ ______________Address Line 1 ________________________________________ _______Address Line 2 ________________________________________ _______City/State/ZIP___________________ _____________________________Phone______ __________________ Organization Number ___________PART 3.

Contribution for Tax Year _____ (Qualified HSA funding distributions from an IRA must be made for the current tax year) 2. Rollover (Distribution from an HSA or Archer MSA that is being deposited into this HSA) ... 3107_2614H HSA Contribution and Investment Selection (5/2012)

  Selection, Investment, Contributions, Contribution and investment selection