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Includes submission addresses for regular and overnight mail and payment instructions to make checks payable to HSA Bank. Captures account holder identity, address, contact details, account number or full Social Security number, and contribution details such as amount, contribution year selection, source, and type (regular or catch-up). Requires signatures, certification, and a date.",{"@graph":63,"@context":118},[64,80,101],{"@type":65,"itemListElement":66},"BreadcrumbList",[67,71,74,77],{"item":68,"name":69,"@type":70,"position":9},"https://docshare.wps.com","Home","ListItem",{"item":72,"name":10,"@type":70,"position":73},"https://docshare.wps.com/template/",2,{"item":75,"name":36,"@type":70,"position":76},"https://docshare.wps.com/template/forms/",3,{"item":78,"name":59,"@type":70,"position":79},"https://docshare.wps.com/template/hsa-contribution-form-use-this-form-to-make-hsa-contributions-by-check/304129/",4,{"url":78,"name":59,"@type":81,"image":82,"author":87,"headline":59,"publisher":90,"fileFormat":93,"inLanguage":57,"description":61,"dateModified":94,"datePublished":95,"encodingFormat":93,"isAccessibleForFree":96,"interactionStatistic":97},"DigitalDocument",{"url":83,"@type":84,"width":85,"height":86},"https://docshare.wps.com/thumbnails/hsa-contribution-form-use-this-form-to-make-hsa-contributions-by-check/304129.png","ImageObject",442,249,{"name":88,"@type":89},"Aurora","Person",{"url":68,"name":91,"@type":92},"DocShare","Organization","application/pdf","2026-09-29","2026-09-19",true,{"@type":98,"interactionType":99,"userInteractionCount":9},"InteractionCounter",{"@type":100},"ViewAction",{"@type":102,"mainEntity":103},"FAQPage",[104,110,114],{"name":105,"@type":106,"acceptedAnswer":107},"How can I make an HSA contribution using this form?","Question",{"text":108,"@type":109},"Use the form to make contributions to your HSA via check. Alternatively, you may log in to myCigna® and link an external checking or savings account to your HSA for one-time or recurring contributions.","Answer",{"name":111,"@type":106,"acceptedAnswer":112},"Where do I mail the completed form and my check?",{"text":113,"@type":109},"Send the completed form with your check to HSA Bank via Regular Mail (P.O. Box 251, Sheboygan, WI 53082-0939) or Overnight Mail (605 North 8th Street, Suite 320, Sheboygan, WI 53081). Make checks payable to HSA Bank.",{"name":115,"@type":106,"acceptedAnswer":116},"What information is required to process my contribution?",{"text":117,"@type":109},"You must provide account number (8 or 12 digits) or a full 9-digit Social Security number, plus account holder details and contribution information such as contribution amount and year, contribution source, and contribution type (Regular or Catch-Up, if eligible).","https://schema.org",{"og:url":78,"og:type":120,"og:title":59,"og:site_name":91,"og:description":61},"article",{"robots":122,"canonical":78},"index,follow",{"doc_id":124,"site_id":56},304129,1790707854,{"code":4,"msg":5,"data":127},{"doc_id":124,"user_id":128,"nickname":88,"user_avatar":129,"doc_module":9,"category_id":35,"category_name":36,"doc_title":59,"doc_description":61,"doc_content":130,"file_id":131,"file_url":132,"file_type":133,"file_size":134,"view_count":76,"is_deleted":4,"is_public":9,"is_downloadable":9,"audit_status":9,"page_count":9,"language":135,"language_code":57,"site_id":56,"html_lang":57,"table_of_contents":136,"faqs":137,"seo_title":138,"seo_description":61,"update_tm":139,"read_time":4},4810365810221,"https://ap-avatar.wpscdn.com/davatar_155a257f0dc6eb9ab79c44ca47cae57d","Health Savings Account (HSA) Contribution Form  \nUse this form for making contributions to your HSA via check.  \nAlternatively, you may log in to myCigna® and simply link an external checking or savings account to your HSA. You can then set up a one-time or reoccurring contribution.  \nIf you would still like to make a contribution via check, then please mail this completed form with your check to: Regular Mail: HSA Bank, P.O. Box 251, Sheboygan, WI 53082-0939  \nOvernight Mail: HSA Bank, 605 North 8th Street, Suite 320, Sheboygan, WI 53081 Checks should be made payable to HSA Bank.  \nFor assistance, please call the number on the back of your ID card.  \n\n| Accountholder Information: |  |  |  |  |  |  |  |  |  |  |  |  |  |  |\n| --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- |\n| First Name: |  | MI: |  |  | Last Name: |  |  |  |  |  |  |  |  |  |\n| Street Address: |  |  |  |  |  |  |  |  |  |  |  |  |  |  |\n| City: |  | State: |  |  |  |  |  |  |  | ZIP Code: |  |  |  |  |\n| Daytime Phone Number: |  |  |  |  |  |  | Email Address: |  |  |  |  |  |  |  |\n| Account Number (8 or 12 digits from your statement or Accounts tab on myCigna®) . |  |  |  |  |  |  |  |  |  |  |  |  |  |  |\n| OR |  |  |  |  |  |  |  |  |  |  |  |  |  |  |\n| Full 9-digit Social Security Number: |  |  |  |  |  | - |  |  |  | - |  |  |  |  |\n| Account Number OR full Social Security number is required. |  |  |  |  |  |  |  |  |  |  |  |  |  |  |\n| Contribution Information |  |  |  |  |  |  |  |  |  |  |  |  |  |  |\n| Contribution Amount: $ |  |  |  |  |  |  |  |  |  |  |  |  |  |  |\n| Contribution for:  Current Year   (yyyy)  Prior Year   (yyyy)\u003Cbr>Note: Prior-year deposits must be received by the federal tax filing deadline. State tax filing and payment deadlines may vary. If you state’s tax filing deadline is earlier than the federal deadline, please check with your state agency or tax advisor for details on prior-year contributions. More information is also available at [taxadmin.org/state-tax-agencies](taxadmin.org/state-tax-agencies. The IRS does NOT allow an)[. The IRS does NOT allow an](taxadmin.org/state-tax-agencies. The IRS does NOT allow an) extension of time to contribute to an HSA, even if you have an individual extension for filing your taxes. If a year is not specified, your contribution will be deposited for the year in which it is received. Any contributions received will be deposited in the cash. |  |  |  |  |  |  |  |  |  |  |  |  |  |  |\n| Contribution Source:  Accountholder  Employer  Employee pre-tax (through Section 125 Plan)\u003Cbr>If you select Employer or Employee pre-tax, please provide the following:\u003Cbr>Employer Name: Contact Name: Phone Number: |  |  |  |  |  |  |  |  |  |  |  |  |  |  |\n| Rules and Conditions Applicable to Contributions |  |  |  |  |  |  |  |  |  |  |  |  |  |  |\n| Contribution Type\u003Cbr>Regular\u003Cbr>Annual maximum contribution limits can vary from year to year. For current contribution maximums, visit [irs.gov](irs.gov).\u003Cbr>Catch-Up\u003Cbr>If you are 55 years of age or older during the calendar year, you may make one additional “catch up” contribution of up to $1,000 . |  |  |  |  |  |  |  |  |  |  |  |  |  |  |\n| Signature |  |  |  |  |  |  |  |  |  |  |  |  |  |  |\n| I certify that I am the HSA member or an individual authorized to execute this transaction. I have read and understand the instructions and any rules or conditions relating to and have met the requirements for making this transaction. I assume full responsibility for this transaction and will not hold HSA Bank liable for any adverse consequences that may result. I have not received tax or legal advice from HSA Bank. If necessary, I will seek the advice of a tax or legal professional to ensure my compliance with related laws. All information provided by me is true and correct and may be relied upon by HSA Bank. |  |  |  |  |  |  |  |  |  |  |  |  |  |  |\n| Signature: |  |  |  |  |  |  |  |  |  | Date: |  |  |  |  |","cbCaiu7GG3GBsBy6","https://ap.wps.com/l/cbCaiu7GG3GBsBy6","pdf",180931,"English","# Accountholder Information\n## Contribution Information\n## Rules and Conditions Applicable to Contributions\n## Signature","[{\"question\":\"How can I make an HSA contribution using this form?\",\"answer\":\"Use the form to make contributions to your HSA via check. Alternatively, you may log in to myCigna® and link an external checking or savings account to your HSA for one-time or recurring contributions.\"},{\"question\":\"Where do I mail the completed form and my check?\",\"answer\":\"Send the completed form with your check to HSA Bank via Regular Mail (P.O. Box 251, Sheboygan, WI 53082-0939) or Overnight Mail (605 North 8th Street, Suite 320, Sheboygan, WI 53081). Make checks payable to HSA Bank.\"},{\"question\":\"What information is required to process my contribution?\",\"answer\":\"You must provide account number (8 or 12 digits) or a full 9-digit Social Security number, plus account holder details and contribution information such as contribution amount and year, contribution source, and contribution type (Regular or Catch-Up, if eligible).\"}]","HSA Contribution Form - Use this form to make HSA contributions by check | PDF",1789810405]