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MEDICAL SAVINGS ACCOUNTS/HEALTH SAVINGS ACCOUNTS
ADMINISTRATOR OF UTAH, INC.
P.O. BOX 65625
SALT LAKE CITY, UTAH  84165-9867
 

                                                       HSA CHANGE FORM
SUBSCRIBER INFORMATION:

_______________________________________________________________________________
                   ( Last name )                                                ( First name )                           ( Initial )

Subscriber Social Security Number:___________________________

ADDRESS CHANGE:

_______________________________________________________________________________
                  ( Street )                                                                                         (Apt. # )

_______________________________________________________________________________
                  ( City )                                                       ( State )                          ( Zip )

NAME CHANGE:

From:___________________________________________________________

To:______________________________________________________________

If reason for change is marriage, check appropriate space below

(  )  I wish to add my spouse to my coverage and have accordingly listed his/her name in the "Addition of Family Members" section.   Date of marriage:____________________________

( )  I do not wish to add my spouse to my coverage.

ADDITION OF FAMILY MEMBERS:

Relationship to Subscriber Full name of Family members Birthday Social
Security
Number
1. . . .
2. . . .
3. . . .

DELETION OF MEMBERS:
Name of member to be deleted Reason for Deletion Effective Date
1.    
2.    
 
OTHER CHANGES THAT ARE NOT IDENTIFIED ON PREVIOUS PAGE
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
SIGNATURE:
I, the undersigned, hereby request Health Savings Accounts
Administrators of Utah, hereinafter known as "the Account Holder"
to change my membership in the H.S.A. Plan as noted hereon,
subject to prevailing rules, regulations and premiums of the,
account holder and in accordance with my present contract with
the account holder.  I understand any change my affect may affect my standing
with the H.S.A. Plan.
______________________________________                                   ____________________
Subscriber Signature                                                                     Date

1425 Yorktown Circle   *  SALT LAKE CITY, UT  84117
801 - 467 - 8012   *  801 - 487 - 4760 VOICE MAIL  *  801 - 467 - 9080