Instructions for Completing

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					                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.

				
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