Chuck Spaeth - Membership & Health Savings Account Application

Name*

First Name

Initial

Last Name

Who does the Health Insurance cover?*

Single Family

Social Security Number*

Date of Birth*

Marital Status*

Phone*

Email*

Best time of day to be contacted*

:

Address*

Address Line 1

City

State

ZIP Code

Mother's Maiden Name*

I authorize SouthPoint Financial Credit Union to give my H.S.A. Account Number to my employer for direct deposit purposes.*

Yes No

I am applying for*

Membership Health Savings Account (H.S.A.)

If you are currently a member of SouthPoint, you only need to select Health Savings Account (H.S.A)

Do you have an existing H.S.A.*

Yes No

I agree to accept my disclosures electronically?*

Yes No

Please enroll me in eStatements & eNotices*

Yes No

Driver's License*

No File Chosen

File uploads may not work on some mobile devices.

In 2023, will you be age 55 or older?*

Yes No

If you obtain age 55 before the close of a taxable year, your contribution limit increases by $1,000 for the annual catch-up contribution.

Do you have a Beneficiary*

Yes No

Beneficiary Name*

First Name

Initial

Last Name

Beneficiary Date of Birth*

Beneficiary Social Security Number*

Beneficiary Address*

Address Line 1

Address Line 2

City

State

ZIP Code

Beneficiary Home/Cell Phone*

Would you like to have an authorized signer?*

Yes No

Signers Information Needed: Signers Name, Social Security Number, Date of Birth, Address, Phone Number and Email.

Driver's License of Signers

No File Chosen

File uploads may not work on some mobile devices.

I would like the following tool(s) to access the funds in my H.S.A.*

Checks Debit Card

I understand that this account will not be complete until my identity has been verified all documents are reviewed and signed by a SouthPoint Financial Credit Union representative. I would prefer to sign the documents via:*

Stopping into a branch Signing electronically