Downloadable Forms

To make it as convenient as possible to have and open an HSA, you may download some of the most commonly used forms right from this site.

Account Setup Forms

HSA Eligibility and Information
Use this form to determine your eligibility to open an HSA.

Health Savings Account Application
Use this form to open an HSA.

Authorized Signer Agreement
There can be only one owner of an HSA.  If you would like for your spouse or third party to transact on the HSA, you will need to complete this form.

Designation of Beneficiaries
If you wish to designate beneficiaries to your HSA, please complete this form.

Contribution Forms

Contribution
Use this form to make a contribution to your HSA.

Withdrawal Forms

Excess Removal
Complete this form when you have gone over your contribution limit and need to remove the excess funds to avoid incurring the tax penalties associated with exceeding the annual limit.

Withdrawal
This form should be used to withdraw funds from your account.

Transfer/Rollover Forms

Transfer/Rollover Request
Complete this form if you currently have a Medical Savings Account (MSA), Flexible Spending Account (FSA), or an HSA with another custodian and want to roll those funds over to your HSA at SEFCU.

Health Savings Account Transfer Request
Use this form to move HSA assets from another financial organization to your HSA at SEFCU.