HSAGROUP-12/17 Member FDIC Page 1 of 1
Company Name:
Address:
City: State: Zip Code:
Phone: Email Address:
Contact Person:
Total Periodic Deposit Amount: Periodic Deposit Frequency:
On behalf of the above named company, I hereby authorize and direct Cattle Bank & Trust to distribute the
total periodic deposit amount, whether received by check or preauthorized funds transfer, in the following
manner:
Account Owner Name Employer Contribution Employee Contribution
If more space is required, please attach a separate sheet.
Cattle Bank & Trust will distribute total periodic deposit amounts according to the above instructions until
these directions are updated or rescinded, in writing.
Company Authorized Signature Date
If sending contribution by mail please mail to: Cattle Bank & Trust
PO Box 467
Seward, NE 68434
Cattle Bank & Trust
Health Savings Account
Group Deposit Direction Form
click to sign
signature
click to edit
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