HSA Checking

Apply for a 1st Source Health Savings Account

If your employer offers a High Deductible Health Plan there is important information you should know before applying for your account. Read our Frequently Asked Questions for more details.

Set-up Your Account

1. Download and print a copy of the disclosures listed below for your records:
   
   • Health Savings Custodial Account Agreement (5305-C) (82k PDF)
   • Disclosure Statement (73k PDF)
   • Agreement for Deposit Accounts (312k PDF)
   • Electronic Funds Transfer Notice of Disclosure (53K PDF)
   • Truth in Savings Disclosure (239k PDF)
   • USA Patriot Act
   • Electronic Bill Payment Authorization & Disclosure (15k PDF)
   • Privacy Policy
   
   
2. After clicking the Apply Online button below, please print and complete the application. You will need to sign your completed application in front of a Notary.
3. If you will have an authorized signer on your account, please complete the Authorized Signer section on the application. Your authorized signer must also have their signature notarized.
4. Include a check for your initial deposit payable to 1st Source Bank.
5. Mail the Forms and your Deposit to:

   1st Source Bank
   Direct Banking Department
   205 W. Jefferson Blvd., Suite 404
   South Bend, IN 46601

6. After we receive your notarized documents and opening deposit, your HSA account will be opened and account materials will be mailed to you.

To start your application, please click the button below to indicate you have read and agree with the disclosures and agreements listed above.

1st Source Bank only accepts applications from customers in northern Indiana and southwestern Michigan.