HSA Forms

New account applications, forms and other correspondence may be printed from your computer, completed at your convenience and directed to: 

SussexBank

Robin Tomlinson, HSA Department
PO Box 353
Franklin, NJ  07416

(973) 940-7950  rtomlinson@sussexbank.com 

New HSA Application Form

Your account application can be found on page 3 of this document.  When you’re ready to open your account, complete this application and mail it with your opening deposit to the address indicated above. 

Rollover Form

Use this form to transfer an existing HSA or Archer Medical Savings Account to SussexBank.  Depending on your circumstances, you may be including this form with your New HSA Application form. Section 3 should be completed with information about the financial institution at which your HSA or Archer Medical Savings Account is currently maintained.  When completing Section 4, please contact your SussexBank HSA representative (shown above) for details you must provide the transferor about SussexBank.  

Contribution Form

If you wish, this form may be used when making future contributions to your HSA (in person or via the mail).  Please note that if you choose not to use this form for future contributions, we will assume that it is a regular contribution, made in the current tax year by the owner of the account. 

Distribution Form

Use this form if you are settling the estate of a deceased account holder, or if you choose to move your HSA to another banking institution.

Our current Health Savings Account rates* are as follows: 

$1,000.00-4,999.99 1.00% Annual Percentage Yield

$5,000.00 and greater 1.51% Annual Percentage Yield 

If you're 55 and older don't forget you can fund your account with an extra $800 for 2007.

If you have had your HDHP and are now just setting up your HSA, you may not reimburse yourself for any prior qualified health care expenses. 

*Annual Percentage Yields (APYs) indicated assume that principal and interest continue to be reinvested at the same interest rate for a one-year period.  Rates are subject to change and are as of 3/19/07.  A minimum opening deposit of $50 is required. An average daily balance of $1,000 each month is required to earn interest, and a $25 fee applies on all closed accounts.  Fees could reduce earnings on the account.