Account Opening Instructions

1. Determine if you qualify to open an HSA. Federal law requires that the following four conditions are met before you may open an HSA:

• You were a participant in a high deductible health plan (HDHP) on the first day of the month in which you open an HSA
• You have no other health coverage
• You are not enrolled in Medicare
• You cannot be claimed as a dependent on someone else's tax return
• Please refer to IRS Publication 969 or consult your tax advisor if you need assistance in determining your eligibility for an HSA.

2. Print (or save a copy to your computer) the First Niagara Bank Health Savings Account Trust Agreement and Disclosure Statement. This document does not have to be signed or returned to us.

3. Print, complete and sign the HSA Adoption Agreement. NOTE: Only one individual may be an owner of an HSA account. If you would like to give withdrawal/payment access to another individual, please complete the "HSA Authorized Signer/Power of Attorney Designation" on page 2 of the HSA Adoption agreement and secure their signature on that form.

4. Print, complete and sign the account signature card.

5. To help us verify your identity, please provide a photocopy of government issued photo I.D. (i.e. driver's license) for the account owner and authorized signer (if any).

6. If you wish to transfer funds from a Health Savings Account from another financial institution: print, complete and sign the HSA to HSA Transfer Request form.

7. Mail these forms with your check for your opening deposit (if any) and copies of your photo identification to:

First Niagara Bank
Telephone Service Center
P.O. Box 514
Lockport NY 14095-0514

When using your HSA for qualified purchases, remember to keep receipts for your tax records.
Please call us if you have any questions at 1-800-421-0004.

• HSA Opening Instructions
• HSA Signature Card
• HSA Adoption Agreement
• Trust Agreement