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PO Box 9351
Des Moines, IA 50306-9351
Health Savings Account
Certificate of Deposit
Complete the information below to open your Health Savings Account Certificate of Deposit (HSA CD). Once completed,
please sign Page 2, and return this form to Principal Bank.
Name (First, Middle, Last)
Social Security Number
Street address (required to open account)
Birth date (MM/DD/YYYY)
Mailing address (if different from Street address)
Daytime Phone Number
Evening Phone Number
Select the term for your HSA CD:
Amount you’d like to deposit to open your HSA CD: (Minimum of $1,000.00) $
Check the box below to indicate how you will fund your HSA CD:
Check Enclosed – Make check payable to Principal Bank.
Transfer funds from my HSA checking account at Principal Bank. Account #
Rollover funds from my Archer MSA or HSA Account (not at Principal Bank). Complete a Rollover Form.
Transfer funds from my Archer MSA or HSA Account (not at Principal Bank). Complete a Transfer Form.
Interest Payments – Tell us how you would like to receive your interest:
Compound my interest and add it to my HSA CD.
Pay interest earned on the HSA CD to my existing HSA checking account at Principal Bank.
Select one of the following:
I am not currently signed up for Principal Bank Online Banking, and if desired, I will go to principalbank.com to
self enroll so I can view my HSA CD balance and interest payments. (There is no additional fee for this service.)
I am currently using Principal Bank Online Banking, and I would like this account added so I can view my HSA
CD balance and interest payments.
Please continue on to Page 2
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Certification and Signature
Certifications: (We will be unab