Sterling HSA Forms
	Account Change Form To change account information, 1 Page (Rev. 11-09)
	Administrative Services Agreement This Administrative Services Agreement is made between Sterling Health Services, Inc. and the individual who signs the Sterling HSA Enrollment Form., 4 Pages (Rev. 6-10)
	Beneficiary Designation Form Beneficiary designation to be made by all applicants, 2 Pages (Rev. 11-09)
	Custodial Agreement This Custodial Agreement is made between CitizensTrust, and individual who signs the Sterling HSA Enrollment Form, 5 Pages (Rev. 6-10)
	Deposit Form For submission of individual deposits, 1 Page (Rev. 2-10)
	Employee Payroll Deduction Salary Redirection Agreement for Health Savings Account, 1 Page (Rev. 11-09)
	Employer ACH Authorization Form Credit / Debit Authorization Form, 1 Page (Rev. 3-10)
	Employer Enrollment Kit An employer's "How To" kit, 5 Pages (Rev. 11-09)
	Employer Group Application 2 Pages (Rev. 11-09)
	Guide to Tax Related HSA Questions Sterling does not give tax advice, consider these as informed guidelines. Specific tax questions should be referred to your CPA or tax preparer., 1 Page (Rev. 2-10)
	Health Savings Account Administration Instructions 6 Pages (Rev. 6-10)
	Individual Application Application., 3 Pages (Rev. 11-09)
	Individual Enrollment Kit How to Set-up a HSA Account, 16 Pages (Rev. 11-09)
	Request for Debit Card To request debit card, 1 Page (Rev. 11-09)
	Request for Disbursement of Sterling HSA Funds To request disbursements, 1 Page (Rev. 4-10)
	Sample HSA Eligible Expenses Sample expenses list - intended as a quick reference guide only. For a list of qualified HSA expenses please see IRS Publication 502 Section 213 (d)., 2 Pages (Rev. 3-10)
	Sterling HSA Brochure 2 Pages (Rev. 9-09)
	Sterling Service Packages & Fees 1 Page (Rev. 3-10)
	Terminate Account Form To close your account with Sterling HSA, 1 Page (Rev. 1-10)
	Transfer of Funds Request Form This form transfers funds from another institution to your Sterling HSA account., 1 Page (Rev. 11-09)

Sterling HRA Forms
	Change or Termination Form 1 Page (Rev. 3-10)
	Employer ACH Authorization Form Credit / Debit Authorization Form, 1 Page (Rev. 3-10)
	Employer Application 7 Pages (Rev. 6-10)
	HRA Brochure Health Reimbursement Arrangements (HRAs) are defined contribution plans that employers own and control for the benefit of their employees., 3 Pages (Rev. 2-10)
	Individual Enrollment Application 1 Page (Rev. 12-09)
	Medical Claim Form 1 Page (Rev. 6-10)
	Request for Dependent Debit Card Use this form to request a new debit card or additional debit card(s) for your dependents on your HRA account., 1 Page (Rev. 12-09)

Sterling POP Forms
	POP Brochure Section 125 Premium Only Plans, often referred to as POP Plans, reduce income tax liabilities for employers and employees., 2 Pages (Rev. 11-09)
	POP Election Form Election Form to Participate in Section 125 Premium Only Plan, 1 Page (Rev. 2-10)
	POP Questionnaire To set up a POP Plan, the questionnaire needs to be completed and returned to Sterling HSA., 5 Pages (Rev. 11-09)

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For additional information, please contact Claremont at 800.696.4543 or info@claremontcompanies.com