Health Savings Program

HEALTH SAVINGS PROGRAM PARTICIPANT APPLICATION

Name: *

AHN Member #: *

Mailing Address: *

City: *

State: *

Zip Code: *

Phone: *

Cell Phone:

Email Address: *

I understand that upon acceptance of my application to the Health Savings Program, I will be required to participate in:

• Three, 2 hour Financial Education Training sessions (Schedule TBA)
• One, 1 hour Credit Counseling session
• Two Financial Education Workshops during the course of the first year of saving.
• (All sessions are free to AHN members interested in the Health Savings Program.)

I understand that upon successful completion of the above I must attend an orientation session with the Health Savings Program Care Coordinator, where I must be prepared to deposit a minimum of $25 to open my Health Savings Account, and continue to make a minimum deposit of $25 each month to receive a dollar for dollar match amount not to exceed $500 per year.

HEALTH SAVINGS PROGRAM PARTICIPANT SURVEY

Please answer the following questions and submit with your application to the Health Savings Program. The information provided will not impact your ability to participate in the program. The information will be used to determine the type of Financial Education Training you will receive. Thank you!

1. I currently have a savings account at a bank or credit union.

    Yes No

2. I currently have a checking account at a bank or credit union.

    Yes No

3. I have an emergency savings fund.

    Yes No

4. I order a free credit report each year.

    Yes No

5. I know what my credit scores are and the reason they matter.

    Yes No

Thank you for completing this survey.