Contribution Form Instructions:
Your check must be made payable to: Bank of America. Indicate your HSA account number on your check.
Contributions should be mailed to:
Bank of America
Health Savings Account
P.O. Box 2931
Milwaukee, WI 53201-2931
Important note: HSA contributions cannot be accepted at Banking Centers or ATMs.
Health Savings Account Contribution Form
(Not for use at Banking Centers or ATMs)
Apply my contribution to:
Health Savings Account Contribution Form
(Not for use at Banking Centers or ATMs)
Apply my contribution to:
Account #:
_______________________
First Name:
_______________________
Last Name:
_______________________
Address:
_______________________
_______________________
City:
_______________________
State:
______
Account #:
_______________________
First Name:
_______________________
Last Name:
_______________________
Address:
_______________________
_______________________
City:
_______________________
State:
______
,
.
Current Year – Code # 010
(must be received by 12/31)
Last Year – Code # 040
(must be received by your tax
filing deadline)
Contribution Amount $
ABA Routing #: 053201610
Deposits may not be available for
immediate withdrawal.
X
_______________________________________________________
Signature Date
,
.
Current Year – Code # 010
(must be received by 12/31)
Last Year – Code # 040
(must be received by your tax
filing deadline)
Contribution Amount $
ABA Routing #: 053201610
Deposits may not be available for
immediate withdrawal.
X
_______________________________________________________
Signature Date
