Health Savings Account (HSA) Contribution Form - HSA Bank 2026

1. Click ‘Get Form’ to open the Health Savings Account (HSA) Contribution Form in the editor.
2. Begin by filling out the ACCOUNTHOLDER INFORMATION section. Enter your first name, middle initial, last name, street address, city, state, ZIP code, and account number. Ensure that you include your Social Security Number as required.
3. Next, move to the CONTRIBUTION INFORMATION section. Specify the contribution for which you are making this deposit and enter the contribution amount in dollars.
4. Indicate the source of your contribution by selecting one of the options: Accountholder and/or family member, Employer, or Employee pre-tax (through Section 125 Plan).
5. Select whether this contribution is for the current year or a prior year by entering the appropriate year in 'yyyy' format. Remember that prior year contributions must be received by April 15 of the following year.
6. Review all entered information for accuracy before saving your form. Once completed, you can print it directly from our platform or download it for mailing along with your contribution check.

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