SIGNATURE AUTHORIZATION FORM

Address for Return Mail:
Bank of Ann Arbor
HSA Processing
125 S. Fifth Ave.
Ann Arbor, MI 48104
734-669-8900 * Fax 734-669-7160 * Website: www.bankofannarbor.com
SIGNATURE AUTHORIZATION FORM
HSA ACCOUNT HOLDER’S NAME AND ADDRESS
Name
Address
City
State
Zip Code
Account Number
Optional: I hereby designate the following individual(s) as additional authorized signer(s) on my Health Savings Account to sign checks, and issue a
separate debit card to allow electronic access to my HSA.
NOTE: If you are using an authorized signer for your HSA, your authorized signer must provide copies of 1 valid form of ID as well.
Authorized Signer Printed Name
Authorized Signer Signature
Social Security No.
Date of Birth
The following ID was viewed and recorded here: ____________________________________________________
Expiration Date: ____________________
(Type and Number, i.e. Michigan Driver’s License)
Account Holder Sign Here X ____________________________________________________
Date ____________________
By signing you acknowledge that the authorized signer is at least 18 years of age and that you have conveyed that the HSA account, checks and/or debit
card are to be used only for qualified medical expenses.
SUMMARY OF TYPES OF IDENTIFICATION
Primary identification should include picture, expiration date, description of
the person, signature, and address.
Note: The Bank will not accept a P.O. Box in place of a residence.
Secondary identification may be required if the primary form of identification
leaves some doubt as to the true identity of the individual.
*Valid driver’s license
*Valid non-driver’s ID
*Valid state or city employee ID
*Valid passport
*Alien registration
*Armed forces ID card
*Valid US Government ID
*Another primary ID
*Social Security card
*Birth Certificate
*Credit cards
*Bank cards
*Valid state or city employee ID
*Valid local company ID
*Police ID
*Voter’s Registration
The identification address must match the address on the application or the
account cannot be opened.
Secondary identification – has components of primary, but not considered
primary. Acceptable as a second piece of identification. Never acceptable to
open an account alone.
NOTE: If you are using an authorized signer for your HSA, your Authorized Signer must provide copies of 1 valid form of ID as well.
Rev 11/10