Health Savings Account (HSA)

This account is a tax-deductible transaction account that allows you to save money for future health care costs and pay for qualified medical expenses, including those not covered by insurance. It’s a simple and smart way to offset the costs of a high-deductible health insurance plan (HDHP). Any unused funds roll over from year to year.

Steps to Opening an HSA

1. Download and print a copy of the disclosures listed below for your records:
   • Health Savings Custodial Account Agreement (5305-C) and Disclosure Statement (pdf)
   • Electronic Funds Transfer Notice of Disclosure (pdf)
   • Fee Schedule for Personal Accounts (pdf)
   • USA Patriot Act
   • Electronic Bill Payment Authorization & Disclosure (pdf)
   • Privacy Notice (pdf)
2. Go to Open An Account below, and 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.
3. If you will have an authorized signer on your account, please complete the Authorized signer section on the application.
4. Include a check for your initial deposit payable to 1st Source Bank (or you may wait for employer funding).
5. Mail the forms and your deposit to:
6. After we receive your notarized documents and opening deposit, your HSA account will be opened, and account materials will be mailed to you.

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.

About HSAs

HSA Checking features and benefits include:

• Funds in the account can be spent on qualified medical expenses*
• Earn interest on your balances
• Free online banking and e-statements – go paperless!
• HSA Resource Plus^® debit card
• Plus, a second free HSA debit card is available upon request for an authorized signer
• Checks are available to order
• Deposits, up to the maximum annual contribution, made for qualified medical expenses* are tax-deductible.
• Withdrawals used for qualified medical expenses are tax-free
• The interest earned is tax-deferred
• Your unspent funds carry over from year-to-year
• Your employer or insurance carrier may change, but you may always keep your funds at 1st Source.

*Qualified Medical Expenses are defined by Federal Employees Health Benefits law and Section 213 of the IRS Code. Information can be found here.

For additional details and guidance regarding HSAs please refer to IRS.gov and be sure to consult your tax advisor.

For additional tips and reminders regarding an HSA refer to this page.

To open an HSA Checking account, you must be enrolled in a High-Deductible Health Plan. The rules that define HDHPs can be complicated. Check with your health insurance provider to determine if your health plan coverage is HSA-compatible.