HSA Deposit Slip - Aetna by bestt571

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									Aetna HealthFund® Health Savings Account                                                                     DEPOSIT SLIP

HSA ACCOUNT NUMBER:                                                        DOLLAR AMOUNT ENCLOSED:

  3 9 7                                                                    $                             .




                                                                                                                                           AetnA HeAltHFund® HSA

                                                                                                                                           cHicAgo, il 60673-1230
                                                                                                                                           23058 network PlAce
To locate your HSA account number, go to aetna.com                         Make checks payable to Aetna HealthFund HSA
and view your HSA transaction history screen.
                                                                           Mail your check and deposit slip to the mailing address
HSA MEMBER NAME:                                                           provided at right. Do not send address changes or
                                                                           correspondence with your deposit.
___________________________________________________
Last Name                            First Name                    MI      Deposits may not be available for immediate withdrawal.
                                                                           All items for deposit are subject to verification and account
Year in which contribution should be applied: 2 0 ___ ___                  agreements and disclosures.
If you do not choose a year, it will be applied to the current tax year.   For additional deposit slips, please go online or call
Prior year contributions must be postmarked between January 1 and the      Membership Services.
applicable Federal tax return deadline (typically April 15).*
*This does not include extensions.
                                                                           [P.o. Box 23058]                    inc11032 10/09




Aetna HealthFund® Health Savings Account                                                                     DEPOSIT SLIP

HSA ACCOUNT NUMBER:                                                        DOLLAR AMOUNT ENCLOSED:

  3 9 7                                                                    $                             .




                                                                                                                                           AetnA HeAltHFund® HSA

                                                                                                                                           cHicAgo, il 60673-1230
                                                                                                                                           23058 network PlAce
To locate your HSA account number, go to aetna.com                         Make checks payable to Aetna HealthFund HSA
and view your HSA transaction history screen.
                                                                           Mail your check and deposit slip to the mailing address
HSA MEMBER NAME:                                                           provided at right. Do not send address changes or
                                                                           correspondence with your deposit.
___________________________________________________
Last Name                            First Name                    MI      Deposits may not be available for immediate withdrawal.
                                                                           All items for deposit are subject to verification and account
Year in which contribution should be applied: 2 0 ___ ___                  agreements and disclosures.
If you do not choose a year, it will be applied to the current tax year.   For additional deposit slips, please go online or call
Prior year contributions must be postmarked between January 1 and the      Membership Services.
applicable Federal tax return deadline (typically April 15).*
*This does not include extensions.
                                                                           [P.o. Box 23058]                    inc11032 10/09




Aetna HealthFund® Health Savings Account                                                                     DEPOSIT SLIP

HSA ACCOUNT NUMBER:                                                        DOLLAR AMOUNT ENCLOSED:

  3 9 7                                                                    $                            .
                                                                                                                                           AetnA HeAltHFund® HSA

                                                                                                                                           cHicAgo, il 60673-1230
                                                                                                                                           23058 network PlAce




To locate your HSA account number, go to aetna.com                         Make checks payable to Aetna HealthFund HSA
and view your HSA transaction history screen.
                                                                           Mail your check and deposit slip to the mailing address
HSA MEMBER NAME:                                                           provided at right. Do not send address changes or
                                                                           correspondence with your deposit.
___________________________________________________
Last Name                            First Name                    MI      Deposits may not be available for immediate withdrawal.
                                                                           All items for deposit are subject to verification and account
Year in which contribution should be applied: 2 0 ___ ___                  agreements and disclosures.
If you do not choose a year, it will be applied to the current tax year.   For additional deposit slips, please go online or call
Prior year contributions must be postmarked between January 1 and the      Membership Services.
applicable Federal tax return deadline (typically April 15).*
*This does not include extensions.
                                                                           [P.o. Box 23058]                    inc11032 10/09

								
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