Opening a Health Savings Account with gbc BANK

HEALTH SAVINGS ACCOUNTS Customer Checklist Customer Identification Form HSA Copy of valid photo ID (drivers license preferred) Copy of utility bill if address is different from ID Copy of ID for authorized user - if applicable Copy of utility bill for authorized user if address is different from ID - if applicable HSA transfer request section on Customer Identification Form, as well as last statement from previous HSA institution including full account number Return all above items to open account. | FDIC-Insured - Backed by the full faith and credit of the U.S. Government Equal Housing Lender NMLS #461229

HEALTH SAVINGS ACCOUNTS We understand that managing healthcare expenses shouldn’t come with a hefty price tag. That’s why we are excited to introduce our hassle-free GBC Bank Health Savings Account (HSA). An HSA is a tax-exempt spending account that is paired with a High Deductible Health Plan (HDHP). It is used to pay certain quali昀椀ed medical expenses. An HSA is not just a bank account, it’s your passport to a healthier and wealthier future. You get peace of mind knowing you have a dedicated fund for your health needs. Eligibility Requirements for an HSA What you need to open an • You are enrolled in a HDHP HSA at GBC Bank • You are not enrolled in another insurance that is • Valid photo ID (drivers license, passport, state id) not a HDHP • You are not enrolled in Medicare • Social Security Number • You can not be claimed as a dependent on someone else’s return • Birthdate • Mailing and Physical Address - if address does not Bene昀椀ts of an HSA match your photo ID, you will need a piece of mail • You can claim a tax deduction for contributions with your name and current address you make to your HSA • Employer and occupation information • Contributions remain in your account until you use them • Authorized signer information - if you choose • The interest earned on HSA funds are tax free to have an authorized signer, you will need the • Distributions are tax free if used for qualifying following: medical expenses • Valid photo ID • HSAs are portable - they stay with you if you • Social security number change employers and funds can still be used for • Birthdate quali昀椀ed medical expenses even if you no longer • Mailing and physical address have a HDHP • Employer and occupation information HSAs at GBC Bank • Bene昀椀ciary information - must be complete and include the following: • No minimum balance requirement • Name • No monthly maintenance fee • Date of birth • Debit card • Social security number • First box of checks FREE • Address • Online banking available with options for bill pay, • Relationship to you mobile deposit and e-statements • Primary or contingent level and • Automatic contributions can be set up from percentage a GBC Bank account to your HSA | FDIC-Insured - Backed by the full faith and credit of the U.S. Government Equal Housing Lender NMLS #461229

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. 

TRANSFER REQUEST Transfer from: HSA Distribution Plan Number: ______________ ______________ ______________ ______________ ______________ ______________ (Note: Please list all accounts numbers to be transferred to GBC ) Distribution amount type: Entire Plan Other _________________________________________________________ (Note: Please Select One ) Dollar Amount Date: _________ Distribution time frame: Immediately (Note: Please Select One ) Distributing Institution: Institution Name: ________________________________________________________________________________________________ Primary Address ________________________________________________________________________________________________ Secondary Address: ______________________________________________________________________________________________ City: _________________________________________ State: _________ Postal Code: __________________ Payment Method to GBC Bank: Mail check ACH Wire Transfer (Note: Please Select One ) FOR INTERNAL USE ONLY *ACCOUNT OWNER #1: DESCRIPTION OF *ACCOUNT OWNER #2: DESCRIPTION OF IDENTIFICATION DOCUMENTS USED (Note: Copy of I.D. to accompany signature card.) IDENTIFICATION DOCUMENTS USED (Note: Copy of I.D. to accompany signature card.) *Type: *Type: *ID#: *ID#: *Issue Place: *Issue Place: *Issue Date: *Issue Date: *Expiration: *Expiration: CONTRIBUTION TYPE: (for new accounts only) REGULAR ROLLOVER DIRECT ROLLOVER TRANSFER CONVERSION DEATH TRANSFER TAX YEAR CONTRIBUTION: CURRENT YEAR PREVIOUS YEAR (for new accounts only) INSURANCE COVERAGE: SELF-ONLY FAMILY INSURANCE EFFECTIVE DATE: First ACH contribution date from employer: