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P.O. Box 43653 Louisville, KY 402530653 (502) 2441161 (800) 919BMSIFAX (502) 2441162www.small.reelection FORM FOR THE HEALTH SAVINGS ACCOUNT HSA BANK PLEASE COMPLETE ALL FIELDS ON THE FORM AND PRINT

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5. Double-check your entries for accuracy and completeness.
6. If any supporting documents are needed, attach them securely to the form.
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