PA ABLE

Progress

Steps

1 About the Account Owner

2 Choose Investments

3 Pick a Contribution Method

4 Choose a Delivery Method

5 Security

6 Complete the Account

tips

Who is the Account Owner?

The Account Owner is the Eligible Individual with the disability, as defined in the Plan Disclosure Booklet.

The Account Owner must:

Be a U.S. citizen or legal resident alien.
Have a Social Security or Taxpayer Identification Number.
Have a permanent U.S. street address (not a P.O. Box).

What is an Authorized Individual?

An Authorized Individual has the authority to open or manage an Account for the benefit of the Account Owner. The Account Owner maintains ownership of the money in the Account.

Who can serve as an Authorized Individual?

The Authorized Individual is the person or entity who can transact on the Account on behalf of the Account Owner. The Authorized Individual may be the Account Owner’s agent under a power of attorney or, if none, a conservator or legal guardian, spouse, parent, sibling, grandparent of the Account Owner, or a representative payee appointed for the Account Owner by the Social Security Administration, in that order.

The Authorized Individual is the person or representative of an entity or organization who can transact on the Account on behalf of the Account Owner. For eligible adults with Legal Capacity as defined in the Plan Disclosure Booklet, the Plan requires that the Eligible Individual must designate the person or entity opening the Account as the Eligible Individual's power of attorney before that person or entity can proceed to open or manage an Account. The Plan may also require documentation to confirm the Authorized Individual's relationship to the Account Owner. Please see the Plan Document Requirements to determine what documentation, if any, is required.

Who is opening the Account?

Alert

Select for whom you are opening this Account?

I am opening the Account for myself.

I am opening the Account as the person or representative of an entity with authority to open the Account for an eligible minor.

I am opening the Account as the person or representative of an entity with authority to open the Account for an eligible adult who has Legal Capacity as defined in the Plan Disclosure Booklet.You are required to have a power of attorney from the Eligible Individual.

I am opening the Account as the person or representative of an entity with authority to open the Account for an eligible adult who does not have Legal Capacity as defined in the Plan Disclosure Booklet.

To open an Account as an Authorized Individual on behalf of the Account Owner, the Authorized Individual must provide official documents confirming their relationship to the Account Owner. Documents can be uploaded during the online account opening process. Appropriate documents must be uploaded (or otherwise provided) and approved by PA ABLE before the account will be activated.

Typical documentation is listed below for each Authorized Individual type. In some cases, other documents might be required to establish the Authorized Individual's authority and relationship to the account owner. Please contact PA ABLE if documentation is not available or if you have questions about documentation requirements.

Authorized Individuals may provide scans or copies of any required documents with the application, but should maintain originals or certified copies and be able to produce them for PA ABLE or Internal Revenue Service upon request.

Please Note: If you are opening the Account on behalf of an eligible adult that has Legal Capacity as defined in the Plan Disclosure Booklet, you are required to submit a Power of Attorney Form completed by the Eligible Individual.

Authorized Individual Type:	Typical Documentation:
Power of Attorney	Power of attorney signed by the Account Owner. Please note that the Power of Attorney must be notarized.
Conservator	Letters of appointment issued by a court
Legal Guardian	Letters of appointment issued by a court, granting appropriate financial authority
Spouse	Marriage certificate
Parent	Account Owner's birth certificate confirming Authorized Individual is the Account Owner's parent
Sibling	Account Owner's and sibling's birth certificates confirming a common parent
Grandparent	Account Owner's and parent's birth certificates confirming Authorized Individual is the Account Owner's grandparent
SSA-appointed Representative Payee	Documentation issued by the Social Security Administration appointing Authorized Individual as representative payee

About the Account Owner

Alert

Please specify First Name

Please specify Last Name

Please specify Mailing address

Please specify Mailing address City

Please specify Mailing address State

Please specify Mailing address Zip Code

Please specify Permanent address

Please specify Permanent address City

Please specify Permanent address State

Please specify Permanent address Zip Code

Please correct the Telephone Number field

Please enter a valid email address

Please retype your email address.

Please specify Date of Birth

Please specify Social Security

Please select eligibility type

Please select disability code

You may open only one ABLE Account per Account Owner.

This is the Eligible Individual whose Qualified Disability Expenses will be paid from this Account.
If you are enrolling on behalf of the Account Owner, you will add your information later in this process.

First name		MI		Last name

Permanent street address (No P.O. Box)

Permanent Address line 2

City		State		Zip
				- Zip Extension

Check if the mailing address is the same as the permanent street address

Account Owner mailing address

The Account Owner's mailing address indicated here will be used as the Account's address of record for all Account mailings. Duplicate statements will also be mailed to the Authorized Individual's mailing address.

Mailing address line 2

City		State		Zip
				- Mailing address ZIP extension

Direct Telephone Number		How did you hear about the Plan?
- - Phone area code Phone next three digits Phone last four digits
A code will be sent (call or text) to this number to log in.

Re-enter the email to which all communications from the Plan should be sent.

Re-enter the email to which all communications from the Plan should be sent. There can only be one email address for the Account. The Account Owner and Authorized Individual should agree on the email address to be used.

Email address		Retype email address

Social Security or Taxpayer Identification Number

Birth date

- - Social Security or Taxpayer Identification Number first three digits Social Security or Taxpayer Identification Number next two digits Social Security or Taxpayer Identification Number last four digits

Date of birth month Date of birth day Date of birth year

Citizenship
U.S. citizen		Resident alien Country code

Please select the Account Owner's disability, the onset of which occurred prior to their 46th birthday:
(The following information is required by the federal government. Report only one primary code for an Account Owner. If more than one code applies, select most significant code.)

Note: Please DO NOT submit your written disability-related diagnosis or any protected health information (PHI). If we receive any PHI we will destroy it using secure means. For any additional questions please contact the PA ABLE Plan at (855) 529-ABLE(2253).

Code 1 - Developmental Disorders: Autistic Spectrum Disorder, Asperger’s Disorder, Developmental Delays and Learning Disabilities

Code 2 - Intellectual Disability: May be reported as mild, moderate, or severe intellectual disability

Code 3 - Psychiatric Disorders: Schizophrenia, Major depressive disorder, Post-traumatic stress disorder (PTSD), Anorexia nervosa, Attention deficit/hyperactivity disorder (AD/HD), Bipolar disorder

Code 4 - Nervous Disorders: Blindness, Deafness, Cerebral Palsy, Muscular Dystrophy, Spina Bifida Juvenile-onset Huntington’s disease, Multiple sclerosis, Severe sensorineural hearing loss, Congenital cataracts

Code 5 - Congenital Anomalies: Chromosomal abnormalities, including Down Syndrome, Osteogenesis imperfecta, Xerodermatic pigmentosum, Spinal muscular atrophy, Fragile X syndrome, Edwards syndrome

Code 6 - Respiratory Disorders: Cystic Fibrosis

Code 7 - Other: Includes Tetralogy of Fallot, Hypoplastic left heart syndrome, End-stage liver disease, Juvenile-onset rheumatoid arthritis, Sickle cell disease, Hemophilia, and any other disability not listed under Codes 1 - 6

Basis under which ABLE eligibility is asserted: (Select only one)

To be eligible for an ABLE Account, the Account Owner’s disability must have begun before the age of 46. The Account Owner must also meet one of the requirements below. Refer to the Plan Disclosure Booklet for a full description of Account eligibility. Please select whichever statement applies best:

The Account Owner is receiving SSDI (Social Security Disability Insurance) based on a disability.

The Account Owner is receiving or is entitled to SSI (Supplemental Security Income) based on a disability.

The Account Owner’s disability is identified on the Social Security Administration’s List of Compassionate Allowances Conditions. The disability causes marked and severe functional limitations.

A doctor diagnosed the Account Owner with a physical or mental disability. The disability causes marked and severe functional limitations. It is expected to last for more than 12 months, or is a terminal condition. I will keep a copy of the diagnosis that is signed by a physician who meets the criteria of Section 1861(r)(1) of the Social Security Act and includes the physician’s name and address, as well as the date of the diagnosis. Please DO NOT submit your written disability-related diagnosis, only check this box and keep your diagnosis documentation with you.

Note: For purposes of ABLE eligibility, marked and severe functional limitations means the standard of disability in the Social Security Act for children claiming SSI benefits, but without regard to age or whether the Account Owner engages in substantial gainful activity. Specifically, this is a level of severity that meets, medically equals, or functionally equals the severity of any listing in appendix 1 of subpart P of 20 CFR part 404. See 20 CFR 416.906, 416.926a. Refer to the Plan Disclosure Booklet for an additional description.

Account Owner's Identity Verification

To help the government prevent the funding of terrorism and money laundering activities, federal law requires all financial institutions to obtain, verify and record information that identifies each person or entity who opens, owns, or manages an Account.

Driver's license, state-issued I.D. card, or military I.D. card number		Issuing state		Expiration date
				participantInfo.identExpiryDateIdMonth participantInfo.identExpiryDateIdDay participantInfo.identExpiryDateIdYear ID Card expiration date month ID Card expiration date day ID Card expiration date year

I.D. card type		Mother's maiden name

The Account Owner does not have a driver’s license, state-issued I.D. card, or military I.D. card, and by checking this box I acknowledge that I will not be eligible to invest in the Checking Account Option.

By checking this box you are certifying under penalties of perjury that the Account Owner does not have an existing ABLE Account other than an ABLE Account that will terminate via Rollover or a program-to-program transfer of its assets into this Account. Note: An individual may only have one ABLE Account nationwide.