Health Saving Account (HSA) Set-up / Change

Which YMCA Association *
Is this a new account or a deduction change? *
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PLAN INFORMATION

Plan Coverage: *
Marital Status: *

Primary Beneficiary Information


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2. Primary Beneficiary Information


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3. Primary Beneficiary Information


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4. Primary Beneficiary Information


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Would you like to add Contingent beneficiaries? *

Contingent Beneficiary Information (if any)

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2. Contingent Beneficiary Information

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3. Contingent Beneficiary Information

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4. Contingent Beneficiary Information

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Additional Information

Account statement delivery: *
On-line access to view account? *
Debt card will be issued. Would you also like checks for additional charge *

If others are to have access to the account with a debit card or writing checks, please include their information below.

Do you want to add other individuals to have access to your account? *
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Deposit amount and signature

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I hereby authorize Glacial Community YMCA to make pre-tax deduction from my payroll and contribute those funds to my health savings account. This deduction will remain in effect unless I choose to make changes by submitting a change form. *
I hereby authorize the YMCA of Northern Rock County to make pre-tax deduction from my payroll and contribute those funds to my health savings account. This deduction will remain in effect unless I choose to make changes by submitting a change form. *
Signature *
clear
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