Forms
Whatever the situation, we have the forms to assist you.
Account Opening
HSA Application
Use this application to open your HSA with HSA Resources. Note: if you are participating in an employer plan, you can skip Section 2 as that information will be provided by your employer.
HSA Application for Groups
Use this application to open your HSA with HSA Resources. Note: use this Application for only if you are participating in an employer HSA plan.
Transfers and Rollovers
Use this form to transfer an HSA/MSA/FSA/HRA from another administrator. If you have already closed your HSA with the other administrator and received a check, please use the HSA Contribution Form.
Ongoing Account Maintenance
Change of Beneficiary
Complete this form to identify who you would like to inherit your HSA or to change your beneficiaries. Note: if you designate your spouse, your HSA will transfer tax free and become your spouse’s HSA.
HSA Contribution Form
To make additional contributions to your HSA please complete, sign and submit this form along with your contribution. Note: you may check your total contribution limit with our HSA Contribution Worksheet.
HSA Authorized Signer Form
Use this form to give an additional person authorization to sign checks and use a Falcon National Bank MasterCard™.
HSA Distribution Form
If you would like to take a distribution to pay for a medical expense and do not want to use your checking account or Falcon National Bank MasterCard™, you may also submit a completed Distribution form.
Excess Contribution
If you contribute too much to your HSA, you need to remove the “excess” amount plus any interest earned on the excess by your tax filing due date to avoid penalties. Use this form to remove excess contributions.
Re-Contribution of Mistaken Distribution
Use this form if you mistakenly take a distribution for an expense that you thought was “eligible”. Re-contributions must be corrected by your tax filing due date following the year you should have known of the mistake.
Death Distribution
In the case of a death, the account holder’s HSA will pass to the designated beneficiaries upon submission of a copy of the death certificate and Distribution Form. Note: surviving spouses inherit the HSA as their HSA, tax-free.
Custodial Agreement
The custodial agreement specifies the terms and conditions of your account.
HSA Online Banking Agreement
Use this form to sign up for free internet banking (do not check bill pay).