Health Savings Account Application
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.
First, Set-Up Your Account
- Download and print a copy of the disclosures listed below for your records:
- Health Savings Custodial Account Agreement (5305-C) and Disclosure Statement (pdf)
- Agreement for Deposit Accounts (pdf)
- Electronic Funds Transfer Notice of Disclosure (pdf)
- Truth in Savings Disclosure (pdf)
- USA Patriot Act
- Electronic Bill Payment Authorization & Disclosure (pdf)
- Privacy Notice (pdf)
- After clicking the I'd like to apply for a Health Savings Account link below, please print and complete the application. You will need to sign your completed application in front of a Notary if you are not an existing 1st Source checking account client.
- If you will have an authorized signer on your account, please complete the Authorized Signer section on the application.
- Include a check for your initial deposit payable to 1st Source Bank (or you may wait for employer funding).
- Mail the forms and your deposit to:
1st Source Bank
Online Banking Department
205 W. Jefferson Blvd., Suite 100
South Bend, IN 46601
- After we receive your notarized documents and opening deposit, your HSA account will be opened and account materials will be mailed to you.
Next, Start Your Application