HSA Account Application

Application and Adoption Agreement Instructions

Thank you for your interest in opening a Health Savings Account at First American Bank. To establish your Health Savings Account (HSA) you will need to complete the Application below and print and sign the Adoption Agreement and Designation of Authorized Signer (if applicable) (sections 3-7). Return the signed forms to us either by fax or by mail. Your application will not be processed until we have received your signed HSA Adoption Agreement.
If you have any questions contact us at: (847) 586-2400, toll free at (866) 449-1150 or by e-mail at HSA@FirstAmBank.com. (Please do not provide any confidential information via email).
Submit the Adoption Agreement and Designation of Authorized Signer (if applicable):
  • BY FAX: Fax your form(s) to (847) 264-2308
  • BY MAIL: Mail your form(s) to:
    First American Bank
    Attention: HSA Department
    P.O. Box 0794
    Elk Grove Village, IL 60007-0794
At the end of this package you will find a copy of the 5305-C Health Savings Custodial Account, and the Health Savings Account Disclosure Statement. Keep these documents for your records.

Health Savings Account Application and Adoption Agreement

HSA HSA PLUS
Yes No
Individual Family
Single Married

1. Account Owner Information

Please indicate the type of account you would like to open HSA or HSA Plus, whether you are currently covered under an individual or family plan, and your current marital status. You will also need to complete all required fields for your personal information.
IMPORTANT ACCOUNT OPENING INFORMATION: Federal law requires us to obtain sufficient information to verify your identity and that of the person you designate as your authorized signer. You may be asked several questions and to provide one or more forms of identification to fulfill this requirement. In some instances we may use outside sources to confirm the information. The information you provide is protected by our privacy policy and federal law.
You will need to provide information from a valid identification (not expired or revoked) from the following list:
  • A U.S. state issued Driver's License or Identification Card
  • An identification card issued by a branch of the Armed Forces of the United States
  • A Passport
  • A Consular Card (Matricula Consular issued by the Mexican Consul in the United States).
Complete if mailing address is different from residential address:
We will verify your current address. If we are unable to verify your current address, we will contact you for additional proof of current residence.
If your ID doesn't have an issue or expiration date, then enter 01/01/2001.

1. Account Owner Information (continued)

Authorized Signer and/or beneficiary selection (Select one):
If you select to have an authorized signer, that person will also act as your sole beneficiary.
Authorized signer and beneficiary
Beneficiary only
None

4. Agreement

Review the disclosures in this document. Indicate if you would like to receive a MasterCardĀ® Debit Card, an initial order of checks and a monthly paper statement. Carefully review the tax withholding information. Please print the required information and sign the form. If you are subject to backup withholding from the IRS please make sure you strike out the words for point (2).
The Account Owner name in this Application and Adoption Agreement (Customer) and First American Bank (Custodian) hereby agree to establish a Health Savings Custodial Account ("HSA") under the provisions of the Internal Revenue Code Section 223, other relevant sections, and any additional guidance from the Internal Revenue Service. Customer hereby acknowledges receipt, understanding, and agreement with the terms governing this HSA as described in the Internal Revenue Service Publication 5305-C (the "Custodial Agreement") The Health Savings Account Disclosure Statement (the "HSA Disclosure"), and First American Bank's Rules and Regulations governing its Deposit Accounts (the "Account Rules and Regulations"). I hereby request that the following options apply to my account:
Issue a MasterCardĀ® Debit Card to Account Owner
Send an order of 50 HSA Checks. (Additional Fee will apply).
I prefer to receive a paper copy of my account statement. I understand that there is a fee for this service. To receive a PDF copy of your account statement at no charge, you must enroll in our On-line Banking Service within 30 days of account opening.
An e-statement may be provided, free of charge, if you provide us with your e-mail address.
The Internal Revenue Service does not require your consent to any provision of this document other than the certifications required to avoid back-up withholding.
Tax withholding certification: Under penalty of perjury, I certify: (1) that the tax identification number entered on this form is my correct taxpayer identification number; and (2) that I am not subject to back-up withholding because either: (a) I have not been notified that I am subject to back-up withholding as a result of a failure to report all interest or dividends; (b) the Internal Revenue Service has notified me that I am no longer subject to back-up withholding; or (c) I am an exempt recipient under Internal Revenue Service regulations. Strike part (2) of this paragraph if you have been notified that you are subject to back-up withholding due to under reporting and you have not received a notice from the Internal Revenue Service that back-up withholding has been terminated.