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<br />Health Savings Account (HSA) Employer Application <br /> <br /> <br />Please mail completed form to: <br />Wells Fargo Health Benefit SeNices, NW 5613, P.O. Box 1450, Minneapolis, MN 55485-5613 <br /> <br />Company Information <br />Name City of Centerville <br />Street Address 1880 Main 8t <br />City Centerville State M N IZiP 55038 <br />Federal Employer Tax 10 41-1267014 State d Incorporation MN <br />Websile Address Plan Effective Date 1/1/2008 <br />Plan Name I Carrier ID/Group No. (W required by carrier) <br />Employer Entity (check one) <br />o C Corporation o S Corporation o Partnership o Sole Proprietorship o Nonprofit Organization o Limited Liability Corporation IiIG",ernment Entity or Church <br />HSA Contact Information <br />This should be the person at your company who will I9Celve HSA communication. <br />Main Contact Title <br />Phone (area code) 651-429-32321 Fax (area code) 651-429-8629 E-mail <br />The USA PATRIOT ACT OF 2001 requires f1nanclallnstltuttons to obtain. verify and record Information to eonflrm the Identity of each Individual or entity that opens an aeeount. What <br />this means for you: before you open an account, we will ask for your name, address, dat9 of birth (If you are an Individual). taxpayer identlfleatlon number (TIN), and other Informa1lon <br />tha1 will allow us to Identify you. For entities. opening new aceounts. we Will ask you for documentation tha1 may Inelude annual reports. government Issued business lIeenses or <br />pertnershlp agreements. <br />IE I certify that the purpose and funds for this aceount are for a Health Savings Aeeeunt (HSA). <br />If no. please explain: <br />What Is the source of the funds maintained In the account: <br />~ Payroll 0 Personal Funds 0 Other - If other, please explein: <br />How were you referred to Wells Fargo: <br />Payroll Information <br />Payroll is Prepared Company Payment Options <br />l!J In House o Check <br />o Outsourced (speOOy payroll company) [8 Wire/ACH <br /> o Draw <br />Payroll Contact John Meyer Hie Finance Director <br />Phone grea code) I Ftf5"i':.4:m~8629 E-mail jmeyer@centervillemn.com <br />51-429-3232 <br />Administrative Information <br />Administrative Fee Payment By Number of Employee Enrollment Kits Requested <br />o Company <br />I!I Participant Monthly Administrative Fee <br />o Other (specify): $ 4.25 per account <br />Available Health Plans <br />A Wells Fatga HSA can onlv be offered In conjunction with a high deductible hefllth plan. <br />1. Plan Name <br />Wells Fargo Employer HSA <br />2. Plan Niame <br />3. Plan Name <br /> <br />HSA-ERA <br />3/1512006 <br /> <br />CONFIDENTIAL ONCE COMPLETED AND RETURNED <br /> <br />$ <br />