Forms

Open An Account

Falcon National Bank Forms

Individuals

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 Address

Complete this form if your address changes.

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).

Employers:

Employer Information

This form provides us with basic information on the employer (name, contact person, type of plan) and is designed to be used by employers that are not utilizing the HSA Admin Center. To enroll in the HSA Admin Center click here.

Employer Contribution Worksheet

For employers that are not using the HSA Admin Center and wish to make contributions to employee HSAs. Use this form (or your own) to provide us with a breakdown of the contribution between individual employees. This form may also be used to add or remove employees. Or use this PDF version of the Employer Contribution Worksheet.

Model Notice of HSA Contributions

Sample notice that employers must provide to all employees that fail to open an HSA when the employer is making HSA contributions.

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.

ACH Agreement

For employers that will be conducting regular ACH transfers to fund their employees’ HSAs.

HSA Payroll Deferral Election Form

If you allow employees to do deferrals through payroll, the employee will need to tell you the amount of the deferral. Use this form to obtain employee elections. Note: often, your Section 125 plan provider supplies a form for this purpose.