Client Information Needed for a New Health Savings Account

USA Patriot Act - Important Information about Procedures for Opening a New Account To help the government fight the funding of terrorism and money laundering activities, Federal law requires all financial institutions to obtain, verify, and record information that identifies each person who opens an account. What This Means For You: When you open an account, we will ask for: your name, address, date of birth, and other information that allows us to identify you. We may also ask to see a copy of your driver's license or other identifying documents.

Date of Birth:

(City) (State) (ZIP) Home Phone: Work Phone:

Email:

Please tell us about yourself. Name (First, MI, Last): Tax ID Number (SSN/ITIN): Physical Address:

(Street) Mobile Phone: Mother’s Maiden Name: Employer: Occupation:

Please provide information on your unexpired Driver’s License or other Government issued photo-ID. ___Driver’s License ___Passport ___Resident Alien Card ___Other: Issuing Entity: (MVA, Military, State) Issuing Location: (State or Country) Identification Number: Issue Date: Expiration Date:

Please answer the following question(s). Are you currently or have you ever been a foreign government official, an official of a major foreign political party, or are you an immediate family member, close associate, acting at the direction of or for the benefit of those officials or their corporations or businesses? ___Yes ___No If “Yes,” please indicate the relationship to the official and the foreign country:

Sandy Spring Bank

17801 Georgia Ave.

Olney, MD 20832

(800) 399-5919

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Sandy Spring Bank 17801 Georgia Ave Olney, MD 20832

HSA DEBIT CAR

Name: _____________________ __ _____________________________ Address: _____________________________________________________ City: ______________________ State: __________ Zip Code: __ __ __ __ __

Social Security Number: __ __ __-__ __-__ __ __ __ Mother’s Maiden Name: _________________________

Home or Cell Phone: __ __ __ . __ __ __ . __ __ __ __ Work Phone: __ __ __ . __ __ __ . __ __ __ __

Primary Account Access

Point of Sale access available for Health Savings Account only

HSA Account Number: ________________________________________

I am requesting the service indicated above. I acknowledge receipt of and agree to the Personal Deposit Account and Electronic Banking Agreement and Personal Fee Schedule.

HSA Owner Signature Date

SSB-1010 Debit Card Application Personal Revised 8/2019

FOR BANK USE ONLY

Check Order (Optional)

Order Wallet Style Checks w/ Deposit Tickets- $18.50 will be deducted from your account for a book of 50 checks.

Order Duplicate Style Checks w/ Deposit Tickets- $20.40 will be deducted from your account for a book of 50 checks.

Check order fee subject to change.

Authorized Signer for Health Savings Account

Name of account owner -

Address of account owner (Street address, city, state, zip code)

Date of birth of account owner -

HSA Account Number -

If you wish to designate an authorized signer on your account, please complete all of the required fields below. If you are unable to provide all of the required information about your authorized signer, they will not be added to your account. You hereby designate the following individual as an authorized signer on your Health Savings Account. By designating an authorized signer on your account, you authorize the person designated below as "Authorized Signer" to transact business with and give instructions to Sandy Spring Bank regarding your health savings account; make deposits or withdrawals by any means acceptable to Sandy Spring Bank, including paper and electronic methods such as ACH and Internet-generated transactions; receive and have access to account information, including account balances and transactions; endorse any instruments such as checks, orders or other documents for the payment of funds; and to otherwise serve as agent for your Sandy Spring Bank health savings account. You specifically authorize Sandy Spring Bank, as custodian of your HSA, to rely upon this authorization and designation until such time, if any, that Sandy Spring Bank receives a written revocation of this authorization, and has had a reasonable time to act upon the revocation. You understand that you are responsible for ensuring that your authorized signer reads and understands the Health Savings Custodial Account Agreement, Personal Deposit Account and Electronic Banking Agreement, and Personal Fee Schedule which have been provided to you. You hold harmless and indemnify Sandy Spring Bank against any claims against or losses Sandy Spring Bank may suffer arising out of Sandy Spring Bank's reliance on this authorization, and release Sandy Spring Bank from any liability arising from such reliance, unless otherwise prohibited by law. You understand that you bear sole responsibility for any tax consequences that result from any actions taken by the authorized signer regarding your account. NO PRESENT OR FUTURE OWNERSHIP OR RIGHT OF SURVIVORSHIP IS GIVEN TO THE AUTHORIZED SIGNER BY THIS AUTHORIZATION. UPON NOTICE TO SANDY SPRING BANK OF YOUR DEATH, THIS AUTHORIZATION TERMINATES, AND RIGHTS TO FUNDS IN YOUR ACCOUNT WILL BE TRANSFERRED TO YOUR BENEFICIARIES. IF YOU DID NOT NAME A BENEFICIARY, YOUR ACCOUNT BALANCE WILL ONLY BE PAYABLE TO YOUR ESTATE.

Authorized Signer Information (Please print) All fields are required

Social Security Number _________ --______ --____________ Date of Birth ______ /______ /____________

First Name ______________________________ MI __________ Last name_____________________________________________

Street Address _______________________________________________________________________________________________ Residence only no P.O. Boxes

City _____________________________________ State ________ Zip_____________ Home Phone __________________________

Relationship ___________________________________ Mother’s Maiden Name__________________________________________

Driver's License Number* _____________________________State Issued* _____Issue Date* _________Expiration Date* _________ Gender □ Male □ Female*REQUIRED – If you do not have a valid driver’s license, please contact HSA Support at 800-399-5919 x3155.

_____________________________________ __________ Signature of Authorized Signer Date

I would like second debit card issued for this individual to access my HSA.

_____________________________________ __________ Account Owner Signature Date

Sandy Spring Bank 17801 Georgia Ave Olney, MD 20832

HSA DEBIT CAR

Name: _____________________ __ _____________________________ Address: _____________________________________________________ City: ______________________ State: __________ Zip Code: __ __ __ __ __

Social Security Number: __ __ __-__ __-__ __ __ __ Mother’s Maiden Name: _________________________

Home or Cell Phone: __ __ __ . __ __ __ . __ __ __ __ Work Phone: __ __ __ . __ __ __ . __ __ __ __

Primary Account Access

Point of Sale access available for Health Savings Account only

HSA Account Number: ________________________________________

I am requesting the service indicated above. I acknowledge receipt of and agree to the Personal Deposit Account and Electronic Banking Agreement and Personal Fee Schedule.

Authorized Signer Signature Date

SSB-1010 Debit Card Application Personal Revised 8/2019

FOR BANK USE ONLY

Check Order (Optional)

Order Wallet Style Checks w/ Deposit Tickets- $18.50 will be deducted from your account for a book of 50 checks.

Order Duplicate Style Checks w/ Deposit Tickets- $20.40 will be deducted from your account for a book of 50 checks.

Check order fee subject to change.

AUTHORIZED SIGNER

Debit Card Application.pdfHSA Account Number: ________________________________________

Client Information Needed for New Personal Acct.pdfUSA Patriot Act - Important Information about Procedures for Opening a New Account

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