Instructions for Completing Health Savings Account Adoption Agreement Things you will need before you begin: Driver’s License or other valid ID (passport, etc.) Social Security Number Mother’s maiden name Beneficiary’s Social Security Number and birth date Checking Account routing number and account number (optional) Health Savings Account Adoption Agreement Please read the Instructions and HSA Eligibility Requirements sections completely before proceeding. Section A – Account Opening Information 1. Please print in pen all information required. When possible always give email address. “Mother Maiden Name” is used for security reasons. 2. Brokerage Firm Designation: Please enter “NPC / PERSHING” into the area provided. 3. Form of Identification: You need to enter your valid driver’s license number or other acceptable form of ID number in area provided. Section B – Account Funding and Type of Contribution 1. Minimum initial contribution is $100 check made payable to First DuPage Bank. 2. You do not need to complete this section if you are Transferring a HSA. Section C – Transfers/Rollovers 1. You do not need to complete this area if you are opening a HSA for the first time. 2. If you are Transferring a HSA, please enter approximate amount to be transferred in area provided. 3. Please attach a copy of your most recent HSA statement. 4. You will need to complete the FlexHSA Transfer form. 5. Check with your past HSA company to determine if any transfer forms are to be completed. Please note, they may charge a fee to close out and transfer the account. Section D – Authorization for Automatic Contributions (ACH Debit) (optional) 1. Please note that if you use this feature the dollars deposited are after tax. Your contributions can be taken as an “above the line” deduction when you file taxes that year. 2. You must attach a voided check or deposit slip to the Adoption Agreement to activate this feature. Section E – Fees 1. Please be sure to read through the Services and Fee Schedule. Please note that the Establishment Fee of $18 has been waived. Section F – Checking and Debit Card Issuance 1. The statement “Checks (Initial pack of 25 issued at no charge)” is INCORRECT. There is a charge for checks. Please see the Services and Fee Schedule for more information. 2. If you wish to have just the debit card, check the box for “no.” 3. If you wish to have checks and the debit card, check the box for “yes.” Section G – Additional Authorized Signature (Optional) 1. Complete this section if you wish to have another individual (i.e. spouse) listed as an authorized signer for your account. 2. You can also choose a second debit card for this individual to use for qualified medical expenses. Section H – Web Access and Monthly Account Statement Election 1. Select the option you would like for your monthly account statement. Please note there is a fee of $1 for a paper copy to be sent to you. Section I – Account Beneficiary Information 1. You must elect at least one beneficiary. 2. If married you must list spouse name, Social Security Number, Birth Date and percentage. You cannot assume the account will pass to spouse automatically at your death. Section J – Account Holder’s Acknowledgement and Signature 1. Please be sure to read Acknowledgement carefully before signing. 2. Be sure to date the document the same date as all other forms you may be completing for this account. Instructions for Completing NPC – New Account Form/Application Things you will need before you begin: Driver’s License or other valid ID (passport, etc.) Social Security Number Employer’s Address Financial Information such as yearly income, Fed./State Tax Margin Estimated Net Worth NPC – New Account Form/Application Please print in pen all information required for this Application. This form must be completed and submitted with the Adoption Agreement in order to set up the FlexHSA account. Any area left blank will result in the delay of the application being processed until such time as the information can be obtained and form completed. Why do you have to complete this form? Although you are initially establishing a FlexHSA for your qualified medical expenses, your account may eventually grow to a level where you are able to invest your funds into marketable securities. NPC will need to have all pertinent information about the owner of the FlexHSA on file. This information help to make sure that any investment recommendations made to you are suitable for your investment objectives and investment time horizons. Please be assured that this form will be treated as personal and confidential material and will not be shared with anyone not involved in the establishment of your FlexHSA account. Please retain the Customer’s Copy of the New Account Form as well as the additional pages of disclosure. Account Registration Check “Individual” box. Customer Information Please complete all areas. If an area doesn’t apply i.e. “dependents” please enter “0” or “n/a” for not applicable. Do not leave any area blank. Joint/Custodian Information Since the FlexHSA is owned by one person, do not complete this section. Account Settlement Instructions Leave this section blank – do not check any boxes as it does not apply to the establishment of a FlexHSA account. Affiliations Please read through the questions for Customer #1 and answer them as appropriate. If the answer is “No” you must check “No”. Do not leave blank. Do not check any boxes under the Customer #2 section as there is no Joint owner on the FlexHSA. Verification of Identity – Exemption Status Please read section carefully and answer for Customer #1 only. Leave Customer #2 blank. Verification of Individual Pleases provide valid Driver’s License or other ID. Complete for Customer #1 only. Leave Customer #2 blank. Financial Information Approximate Income – check box that applies Federal/State Max. Tax Margin – check box that applies. Estimated Liquid Net Worth – includes assets such as you home(s), car(s), other personal property, investments, etc. Investment Objectives Primary Investment Objective – rank objectives 1 to 4 to the best of your knowledge. Please see Paragraph 13 of Customer Disclosures and Responsibilities for complete descriptions of these objectives. Risk Tolerance – check the box that most closely describes your risk tolerance. Time Horizon – check the box that most closely describes your time frame for needing the money invested. Years of Experience – please indicate how many years you have owned any of the types of investments listed. If you have not owned a type of investment you must indicate “0”. Do not leave area blank. Acknowledgements Please read the questions and answer appropriately. For question “What is the initial Source of Funds?”, you may answer any of the following that apply: -“personal checking account for FlexHSA” -“transfer of funds from HSA to FlexHSA” Please sign and date in Customer Signature area. Please leave Joint Owner/Tenant area blank. Registered Rep. will sign and date form as well.