Health Savings Account Forms & Procedures

Step 1: 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.*

Step 2: Account Application & Disclosures

Print the HSA Account Application Form, complete it and sign it. Mail this along with the Customer Information and Contribution Form.*

Step 3: Contribution Eligibility

Print the HSA Contribution Eligibility Form, complete it and sign it. Mail this along with the Customer Information Form and Account Application.*

Step 4: Mail Completed Forms

Mail all of the completed forms and initial deposit of $25.00** to:
The Stephenson National Bank & Trust
Attn: HSA Services
1820 Hall Avenue
Marinette, WI 54143-0137

Additional Forms:

Use the Transfer Request Form if you are interested in transferring your existing HSA to SNBT from another financial institution. Submit this form in addition to Steps 1-4.
Use the Designation of Beneficiary if you already have your HSA at SNBT but wish to change your beneficiary information.

*Please retain copies of all forms for your records
**$15 minimum required to open plus $10 application fee