HSA forms

Account owners

HSA forms for account owners

Everence Federal Credit Union Membership and Health Savings Account Application

Everence Federal Credit Union HSA Disclosure Statement

Everence Federal Credit Union HSA Custodial Agreement

HSA Eligibility Worksheet

Everence Federal Credit Union HSA Debit Card Application¹

HSA Limited Power of Attorney Form

HSA Contribution Form

HSA Distribution Request Form

HSA Beneficiary Change Form

Direct Transfer or Rollover of MSA or HSA Funds

Transfer of IRA Funds to an Everence HSA

HSA Investment Option Agreement

HSA Investment Choice Form

HSA Investment Choice Change Form

HSA Investment Liquidation Request Form

Request for Return of HSA Excess Contributions

Request to Close HSA

Eligible Expenses for HSA

HSA Change Form

Employers

HSA forms for employers

Everence Federal Credit Union HSAs – A Summary for Employers

Everence Federal Credit Union HSA Group Contributions

Open a Health Savings Account

Contact a service representative for assistance with HSA requests.

HSA account application Learn more about HSAs

Return completed forms to your local branch or to HSA services.

Everence Federal Credit Union

HSA services
1110 N. Main St.
P.O. Box 483
Goshen, IN 46527
T: (800) 348-7468 ext. 2460
F: (574) 537-3627
E: hsaservice@everence.com

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Disclosure

¹ When applying for an HSA debit card, please read the HSA debit card disclosure.