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

Step 3: 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.*

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:

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