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Get DE The Bancorp Bank HSA Signature Card 2013-2024

Please mail any opening deposit checks made payable to The Bancorp Bank HSA in a postage-paid envelope or send it to The Bancorp Bank HSA 409 Silverside Road Suite 105 Wilmington DE 19809. I have reviewed a copy of the Application the HSA Agreement and the Disclosure Statement available at www. mybancorphsa.com. I authorize the transfer of information as necessary for the purpose of providing bank account summary information from my account at The Bancorp Bank to my account at Independence Blue Cross. Determining that I am eligible for an HSA each year I make a contribution. 2. Ensuring that all contributions I make are within the limits set forth by the tax laws. 3. The tax consequences of any contribution including rollover contributions and distributions both allowable and unallowable. This deposit account is subject to all applicable rules and regulations adopted by The Bancorp Bank. Mybancorphsa.com. I authorize the transfer of information as necessary for the purpose of providing bank account summary information from my account at The Bancorp Bank to my account at Independence Blue Cross. and conditions. Within seven 7 days from the date I open this HSA I may revoke it without penalty by mailing or delivering a written notice to the Custodian. I assume complete responsibility for 1. 283. 1534 F 302. 791. 5771 E myBancorpHSA thebancorp.com Banking services provided by The Bancorp Bank Member FDIC Equal Housing Lender Powered by The Bancorp Bank endorsed by Verify Information Name SSN/Tax ID Date of Birth Driver s License and State Issued Account Number Home Phone Email Address Work Phone Authorized Signer Since IRS regulations require that only one individual owns the HSA Account the account holder may want his/her spouse and/or authorized signer to write checks or use his/her Debit Card. 5 EASY STEPS 1. Please review and verify information 2. Add an Authorized Signer POA 3. Designate a Bene ciary 4. Complete Signature section HSA SIGNATURE CARD 5. Return in the postage-paid envelope 409 Silverside Road Suite 105 Wilmington DE 19809 P 800. I account holder hereby designate the following individual as additional authorized signer on my Health Savings Account. Check here to provide a debit card to my authorized signer Designation of Bene ciaries Important - Please read before signing The following individual s or entity shall be my primary and/or contingent bene ciary ies. If neither primary nor contingent is indicated the individual or entity will be deemed to be a primary bene ciary. If more than one primary bene ciary is designated and no distribution percentages are indicated the bene ciaries will be deemed to own equal share percentages in the HSA. Multiple contingent bene ciaries with no share percentage indicated will also be deemed to share equally. If any primary or contingent bene ciary dies before me his or her interest and the interest of his or her heirs shall terminate completely and the percentage share of any remaining bene ciary ies shall be increased on a pro rata basis.

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