2000 N. Classen Blvd., 7E
Oklahoma City, OK 73106
Toll Free: (866) 326-3600
Local: (405) 523-5699
Fax: (844) 560-6754
Website: www.afhsa.com
Email: afhsa_receipts@alegeus.com
HEALTH SAVINGS ACCOUNT
Investment Fund Election Form
Completed form may be faxed to (844) 560-6754 or emailed to afhsa_receipts@alegeus.com.
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 Cap Index Adm
LARGE CAP EQUITY
VIMAX
$
MONEY MARKET & FIXED INCOME
American Funds American Mutual R6
RMFGX
$
American Funds Growth Fund of Amer
R6
RGAGX
$
Harbor Capital Appreciation Instl
HACAX
$
Vanguard GNMA Adm
Invesco Short-Term Inv Treasury Instl
$
Vanguard Total Bond Market Index Adm
Vanguard 500 Index Admiral
VFIAX
$
Templeton Global Bond Adv
T. Rowe Price Equity Income
PRFDX
$
ASSET ALLOCATION FUNDS
Vanguard Target Retirement Income Inv
SMALL CAP EQUITY
VBTLX
$
VFIJX
$
TGBAX
$
VTINX
$
Keeley Small Cap Value A
KSCVX
$
Vanguard Target Retirement 2015 Inv
VTXVX
$
Morgan Stanley Inst Small Co Gr I
MSSGX
$
Vanguard Target Retirement 2025 Inv
VTTVX
$
American Beacon Stephens Small Cap
STSIX
$
Vanguard Small Cap Value Index Adm
VSIAX
$
Vanguard Target Retirement 2045 Inv
Vanguard Target Retirement 2055 Inv
INTERNATIONAL EQUITY
American Funds Europacific Growth R6
Vanguard Target Retirement 2035 Inv
RERGX
$
Harbor International Institutional
HAINX
$
Artisan International Investor
ARTIX
$
American Funds American Balanced R6
VTTHX
$
VTIVX
$
VFFVX
$
RLBGX
$
*TOTAL
$
*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
M-3263-0715
Date