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Health Savings
Account Forms & Procedures |
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Customer Information
Print the Health Savings
Account Customer Information Form, complete it and sign it. Mail this
along with the Account Application and Contribution Form.* |
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Account Application
Print the HSA Account
Application Form, complete it and sign it. Mail this along with the
Customer Information and Contribution Form.* |
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Eligibility and Information
Print the HSA Eligibility and
Information Form, complete it and sign it. Mail this along
with the Customer Information Form and Account Application.* |
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Mail Completed Forms
Mail all of the
completed forms and an initial deposit of $75.00** to:
The Stephenson National Bank & Trust
Attn: HSA Services
1820 Hall Avenue
Marinette, WI 54143-0137 |
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Designation of Beneficiary
Transfer Request
Withdrawal Statement
Rollover Certification |
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* Please retain copies of all forms for your records. |
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** $50 minimum required to open plus $25 application fee |
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