HSA DIRECT DEPOSIT 2

H                  S
                                                        ​ ​EALTH ​ ​AVINGS​ A​CCOUNT

                                                  ​    DIRECT DEPOSIT
                                                      ENROLLMENT FORM


Important! Please read and sign before completing and submitting.

I hereby authorize my employer (hereinafter “Company”) to deposit any amounts owed me by initiating credit entries to my account at the financial institutions
(hereinafter “Bank”) indicated on both sides of this form. Further, I authorize Bank to accept and to credit any credit entries indicated by Company to my accounts. In
the event that Company deposits funds erroneously into my account, I authorize Company to debit my account for an amount not to exceed the original amount of the
erroneous credit.

This authorization is to remain in full force and effect until Company and Bank have received written notice from me of its termination in such time and in such manner
as to afford Company and Bank reasonable opportunity to act on it.


Employee Name:_______________________________________

Employee Signature:____________________________________ Date ______________________

Account Information



1. Bank Name ___________________________________________________________________________________________

Routing/Transit # _ _ _ _ _ _ _ _ _                                           Account Number:______________________________________

Type of Account (please check):

                                                        ___Checking                      ____Savings




In ​addition​ to the Board of Education contribution I wish to contribute

$______________ per pay into my ​HSA​ account​.