Toll Free: 1-866-326-3600
Phone:
(405) 523-5699
Fax:
(405) 523-5072
Website: www.afhsa.com
HEALTH SAVINGS ACCOUNT
Investment Fund Election Form
Completed form may be faxed to: (405) 523-5072 or mailed to: A F Health Services Administration, 2000 N Classen Blvd, 7E. Oklahoma City, OK 73106
A. Accountholder Information
Name
Social Security #
Address
Email Address
City, State, Zip
Employer Name*
Daytime Phone
Home Phone
*If the HSA was established separate from your employer, the employer name does not need to be completed.
B. Investment Elections
TOTAL AMOUNT TO BE INVESTED
MID CAP EQUITY
$
Vanguard Mid Capitalization Index Signal
LARGE CAP EQUITY
VMISX
$
MONEY MARKET & FIXED INCOME
American Funds American Mutual R6
RMFGX
$
Invesco Treasury Portfolio
American Funds Grth Fund of Amer R6
RGAGX
$
Vanguard Total Bond Market Index Signal
VBTSX
$
Harbor Capital Appreciation Instl
HACAX
$
Vanguard GNMA Adm
VFIJX
$
Vanguard 500 Index Signal
VIFSX
$
T. Rowe Price International Bond
RPIBX
$
T. Rowe Price Equity-Income
PRFDX
$
ASSET ALLOCATION FUNDS
Vanguard Target Retirement Income
VTINX
$
SMALL CAP EQUITY
$
Keeley Small Cap Value
KSCVX
$
Vanguard Target Retirement 2015
VTXVX
$
Morgan Stanley Inst Small Co Gr I
MSSGX
$
Vanguard Target Retirement 2025
VTTVX
$
American Beacon Stephens Small Cap
STSIX
$
Vanguard Target Retirement 2035
VTTHX
$
Vanguard Small Cap Value Index
VISVX
$
Vanguard Target Retirement 2045
VTIVX
$
Vanguard Target Retirement 2055 Inv
VFFVX
$
American Funds American Balanced R6
RLBGX
$
*TOTAL
$
INTERNATIONAL EQUITY
American Funds EuroPacific Gr R6
RERGX
$
Harbor International Instl
HAINX
$
Artisan International Inv
ARTIX
$
*TOTAL must match the Total Amount to be Invested at the beginning of Section B
I understand that a minimum balance of $2,500 must be maintained in the health savings account in order to be eligible to invest HSA funds in the mutual
funds listed above.
I understand that this Investment Fund Election Form must be received by American Fidelity Health Services Administration (AFHSA) no later than 12:00
p.m. Central Standard Time for the election to be processed for that current business day. If the form is not received in time, the election I am requesting will
be processed the next business day.
I understand that no guarantees can be made as to the investment return of the mutual funds I have selected.
Signature of Account holder
FOR OFFICE USE ONLY
M-3263-0313
RECEIVED BY:
Date
TIME:
PROCESSED ON:
PROCESSED BY: