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Hsa-Cusorglz 4060100 Health Savings Account Thank you for your interest in Cornerstone Community Bank's Health Savings Account (HSA). HSAs can provide significant tax benefits to eligible individuals. Not only can HSAs provide tax benefits related to paying qualified medical expenses, they may also provide benefits similar to many tax-favored retirement plans. In choosing Cornerstone Community Bank as your HSA custodian, you can rest assured your FDIC-insured account is safe, and your investment can grow with our competitive interest rates and low fee structure. Cornerstone is a full-service community bank with a friendly, helpful staff. We offer free 24-hour account access to your HSA through our telephone and online banking systems. eStatements are required allowing for immediate access to your statements while being environmentally friendly. Getting Started Once you purchase a qualified High Deductible Health Plan (HDHP), complete the attached applicable forms legibly and completely. Send or bring the forms to Cornerstone Community Bank with your initial contribution, a photocopy of your driver's license, a $25.00 set-up fee, and $8.65 for your first order of checks. We'll take care of the rest! Within 14 days after we receive your application, you will receive your HSA checks and your Cornerstone HSA debit card (if applicable). Online banking offers the convenience of 24/7 access to your account through our website at www.bankwithcornerstone.com. Once you successfully sign up for online banking, you can access eStatements online - the most efficient way to obtain your monthly account information in a statement format. We also provide anytime access to your account via Telephone Banking at 1.888.375.2113. For personal assistance, feel free to contact us at 262.375.5190 or toll free at 1.888.750.7152. Wolters Kluwer Financial Services - Bankers Systems* CUSTOM MDF. EWIHSAC1 Contribution Limits 2013 2014 Self Only $3,250 $3,300 Family $6,450 $6,550 Over 55 Catch-up Contribution $1,000 $1,000 HSA Fees Set-up $25.00 (waived for HSA/MSA rollovers) Maintenance Free the first year, then $2.00 per month if balance falls below $500.00 Checks $8.65 (no transaction fee) HSA Debit Card Free Tiered Interest Rate See HSA Administrator for current rates You will receive the following year-end forms for tax reporting: 1099 SA - distribution 5498 SA - contributions Certificates of Deposit HSA account balances may be carried over from year to year. Cornerstone Community Bank offers HSA certifcates of deposit with greater earnings potential and a variety of terms available. Our competitive interest rates allow your balance to grow tax-free over time. Wolters Kluwer Financial Services - Bankers Systems* CUSTOM MDF. EWIHSAC1 Health Savings Account Welcome to Cornerstone Community Bank! Instructions to open your Health Savings Account (HSA) at Cornerstone Community Bank: 1. Complete the HSA application completely and legibly. 2. Attach a copy of valid identification for you and your POA. 3. Include an active personal e-mail address for eStatements. Options for submitting your completed application materials: } Scan and email to: [email protected] } Fax to: 262.375.9484 } Drop off at any Cornerstone Community Bank location } Mail to: Cornerstone Community Bank Attn: HSA Administrator 2090 Wisconsin Avenue Grafton, WI 53024 Wolters Kluwer Financial Services - Bankers Systems* CUSTOM MDF. EWIHSAC1 eStatement Enrollment l New Enrollment l Add Accounts to Existing Enrollment l Change Email Address to Existing Enrollment l Cancel Enrollment www.bankwithcornerstone.com Please fill out completely, print Customer Name: and mail this enrollment form to: Personal eMail Address: Home/Cell phone: Cornerstone Community Bank Attn: Personal Banking 2090 Wisconsin Avenue Account Type(s): Account Number P.O. Box 146 Grafton, WI 53024 l Checking l Savings l Checking l Savings Or deliver in person to any Cornerstone Community Bank Checking Savings l l location. l Checking l Savings You will receive an email HSA Account Number: l confirmation notifying you that your enrollment form has been processed. Your eStatement enrollment allows you to retrieve your bank statement through internet banking provided the following criteria are met: 1. Agree to keep an active access ID and password for internet banking. 2. Agree to no longer receive a paper copy of your statement. 3. Agree to notify the bank if your email address changes. You have the right to cancel eStatement at any time by notifying the bank in writing. Please submit your cancellation request in person, by fax at 262.375.9484, or by mail to Cornerstone Community Bank, P.O. Box 146, Grafton, WI 53024. Sign below to accept the terms and conditions. Signature Date TERMINATION I wish to terminate my enrollment for eStatement and receive my statements via U.S. mail. Signature Date Internal Use Only Referred by: Date enrollment completed: Work completed by: Wolters Kluwer Financial Services - Bankers Systems* CUSTOM MDF. EWIHSAC1 . HSA . ............................ Health . Savings . Account . Custodial (includes self-direction) ADDITIONAL INFORMATION Purpose. This Organizer contains documents necessary to establish For Additional Guidance a Health Savings Account (HSA). It meets the requirements of It is in your best interest to seek the guidance of a tax or legal Internal Revenue Code (IRC) Section 223, other relevant IRC professional before completing this document. For more sections, and all additional Internal Revenue Service (IRS) information, refer to IRC Section 223, other relevant IRC sections, guidance. An HSA is established after the Organizer is fully and all additional IRS guidance; IRS publications that include executed by both you (account owner) and the custodian and must information about HSAs; instructions to your federal income tax be completed no later than the due date (excluding extensions) of return; your local IRS office; or the IRS's web site at your income tax return for the tax year. Do not file the HSA www.irs.gov. Custodial Account Agreement with the IRS. Instead, keep it with your records. Terms. A general understanding of the following terms may be helpful in completing your transactions. How to use this HSA Organizer. You must complete and sign the Account Owner. The account owner is the person who Application. An original signed copy of the Application should be establishes the custodial account. For HSA purposes, the kept by the custodian for its records. You should receive a copy of account owner is you. the Application and keep the remaining contents of the HSA Organizer. Community or marital property state laws may require Archer Medical Savings Account (MSA). An Archer MSA is a spousal consent for nonspouse beneficiary designations. tax-favored savings account designed to help you pay for qualified medical expenses if you are an employee of a small Additional Documents employer or a self-employed individual participating in a Applicable law or policies of the HSA custodian may require high-deductible health plan. Archer MSA assets may be rolled additional documentation such as IRS Form W-9, Request for over or transferred to an HSA. Taxpayer Identification Number and Certification. Custodian. An HSA custodian must be a bank, an insurance company, a person previously approved by the IRS to be a custodian of an individual retirement account (IRA) or Archer Medical Savings Account (MSA), or any other person approved by the IRS. HSA. An HSA is a tax-exempt trust or custodial account established exclusively for the purpose of paying qualified medical expenses of you, your spouse, and your dependents. Health Savings Account Organizer-Custodial HSA-CUSORGLZ 1/15/2014 Bankers Systems* MDF. EWIHSAC1 Wolters Kluwer Financial Services - 2014 Page 1 of 12 Health Savings Account (HSA) Application HSA OWNER INFORMATION (Custodian's name, address, and phone number above) 1 NAME, ADDRESS, CITY, STATE, AND ZIP HSA ACCOUNT (PLAN) NUMBER SOCIAL SECURITY NUMBER (SSN) DAYTIME PHONE NUMBER E-MAIL (OPTIONAL) DATE OF BIRTH Type of Health Insurance Plan Coverage (select one): l Self-Only l Family CONTRIBUTION INFORMATION INVESTMENT NUMBER AMOUNT CONTRIBUTION DATE TAX YEAR 2 $ CONTRIBUTION TYPE (select one): l Regular (including Catch-Up) l Contribution from an IRA l Rollover from an HSA l Rollover from an Archer MSA l Transfer from an HSA l Transfer from an Archer MSA l Return of Mistaken Distribution Original Distribution Date DESIGNATION OF BENEFICIARY At the time of my death, the primary beneficiaries named below will receive my HSA assets. If all of my primary beneficiaries die before me, the contingent beneficiaries named below will receive my HSA assets. In the event a beneficiary dies before me, such beneficiary's share will be 3 reallocated on a pro-rata basis to the other beneficiaries that share the deceased beneficiary's classification as a primary or contingent beneficiary. A designation of a beneficiary's primary or contingent classification is generally made by entering a percentage in one of the two columns to the left of the name. In the event a beneficiary is named as both a primary and contingent beneficiary, or if a beneficiary is not assigned to a beneficiary classification, such beneficiary shall be a primary beneficiary. If no percentages are assigned to beneficiaries, or if the percentage total for any beneficiary classification exceeds 100 percent, the beneficiaries in that beneficiary classification will share equally. If the percentage total for each beneficiary classification is less than 100 percent, any remaining percentage will be divided equally among the beneficiaries within such class. If all of the beneficiaries die before me, or if none are designated, my HSA assets will be paid to my estate. This designation revokes and supercedes all earlier beneficiary designations which may apply to this HSA. PRIMARY CONTINGENT RELATIONSHIP DATE OF SHARE SHARE NAME OF BENEFICIARY SSN OR TIN TO HSA OWNER BIRTH ADDRESS, CITY, STATE, AND ZIP % % % % % % % % % % % % % % Total 100% Total 100% Health Savings Account Organizer-Custodial HSA-CUSORGLZ 1/15/2014 Bankers Systems* MDF.
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