CUSTOMER IDENTIFICATION FORM – HSA Member FDIC ACCT# ACCOUNT OWNER: *Name *SS# or *Tax ID# *Date of Birth / / CIF # *MAILING ADDRESS: *City *State *Zip (Note: P.O. Boxes must be accompanied by a Street Address) *PHYSICAL ADDRESS: (if different): *City *State *Zip *TELEPHONE: *Home ( ) - *Cell ( ) - *E-MAIL: *EMPLOYER NAME: *OCCUPATION (Acct. Owner #1): Authorized Signer: *Name *SS# or *Tax ID# *Date of Birth / / CIF: *MAILING ADDRESS: *City *State *Zip (Note: P.O. Boxes must be accompanied by a Street Address) *PHYSICAL ADDRESS: (if different): *City *State *Zip *TELEPHONE: *Home ( ) - *Cell ( ) - E-MAIL: * *EMPLOYER NAME: *OCCUPATION (Authorized Signer): BENEFICIARY DESIGNATIONS: All fields are required for each beneficiary. NAME: SSN: BIRTH DATE: / / ADDRESS: CITY/STATE/ZIP BENEFICIARY TYPE: Primary Contingent RELATIONSHIP: PERCENTAGE: NAME: SSN: BIRTH DATE: / / ADDRESS: CITY/STATE/ZIP __ BENEFICIARY TYPE: Primary Contingent RELATIONSHIP: PERCENTAGE: NAME: SSN: BIRTH DATE: / / ADDRESS: CITY/STATE/ZIP BENEFICIARY TYPE: Primary Contingent RELATIONSHIP: PERCENTAGE: Continued on reverse side *Indicates mandatory information to be obtained. 