Please print and mail forms to Bank of Nebraska, 7223 S 84 St, La Vista, NE 68128. Do not email these forms. These forms contain personal information, such as your social security number. Email is not a secure form of communication.
You must have Adobe Reader™ to view these documents.
Please fill in and complete the Customer Identification Worksheet and the HSA Application. You may download the remaining disclosures for your records.
Please fax the Worksheet and the Application to the bank at 402-331-8570. Do NOT email these documents. Email is not a secure communication.
Customer Identification Worksheet
HSA Transfer Request
Electronic Funds Transfer Agreement
HSA Contribution Form
HSA Debit Card Application
HSA Disclosure Statement
Change of Beneficiary