HEALTH SAVINGS ACCOUNT CUSTODIAL AGREEMENT AND FEE DISCLOSURE STATEMENT
The Account Owner named (“Account Owner,” and also referred to herein using pronouns such as “you” and “your”) is establishing this Health Savings Account (“HSA” or “Custodial Account” or the “Account”) exclusively for the purpose of paying or reimbursing Qualified Medical Expenses of the Account Owner, his or her spouse, and Dependents. The Account is being opened by Acressa Insurance, Inc. (“Custodian,” and also referred to herein using pronouns such as “we,” “us” and “our”). The Account Owner has assigned to this Custodial Account the funds described related to their Health Savings Account. For married persons, each spouse who is eligible to open an HSA and wants to contribute to an HSA must establish his or her own account. The identifying number for an HSA will be the Account Owner’s individual HSA account number.
As Custodian for the Account, we will cause the Account Owner’s funds to be placed into a deposit account (the “Deposit Account”) at a depository institution (the “Depository”) selected by us in our sole discretion. Depository is UMB Bank. You will receive periodic Account statements that will reflect your ownership of your HSA funds held in the Deposit Account. You should retain the Account statement(s) for your records.
While we are acting as Custodian for your Account, all contributions to your HSA (made by you, your employer, a family member or any other person) will be made to us, and we will cause the funds to be deposited to the Deposit Account. We will cause funds to be disbursed from the Deposit Account pursuant to this Health Savings Account Custodial Agreement (as defined below, the “Agreement”. You may not transfer the Deposit Account directly to another depository institution.
At your election, you may dismiss us as Custodian in accordance with Article XII, below, and appoint a successor custodian or trustee authorized to act as such in relation to HSAs under the Code. As soon as is practicable following written notice of the appointment of such a successor custodian or trustee, we will cause the funds in the Deposit Account to be transferred to the successor custodian or trustee.
ACCOUNT OWNER REPRESENTATIONS OF ELIGIBILITY
The Account Owner represents that, unless this Account is used solely to make Rollover or Transfer Contributions as defined below, he or she is eligible to contribute to this HSA; specifically, that he or she: (1) is covered under a High Deductible Health Plan (“HDHP”); (2) is not also covered by any other health plan that is not an HDHP (with certain exceptions described herein for plans providing preventive care and limited types of permitted insurance and permitted coverage); (3) is not enrolled in Medicare; and (4) cannot be claimed as a Dependent on another person’s tax return. Custodian has no obligation to verify that any applicant for an Account is eligible to establish an HSA under applicable laws and regulations.
PURPOSE OF FORM 5305-C
IRS Form 5305-C, on which this section of the Health Savings Account Custodial Agreement is based, is a model custodial account agreement that has been approved by the IRS, with permissible additional provisions that may be agreed to between Custodian and Account Owner. The model agreement provisions provided by the IRS as well as the additional provisions added by Custodian are contained within this Agreement. Also, further provisions applicable to the HSA, including certain disclosures required by various banking laws and regulations, are contained here. An HSA is established subject to the acknowledgment of this Agreement. The Account Owner may acknowledge this Agreement any time during the tax year. An HSA must be created in the United States for the exclusive benefit of the Account Owner.
Do not file Form 5305-C or any part of this Agreement with the IRS. Instead, keep the Agreement with your records.
For more information on HSAs, see Notice 2004-2, 2004-2 I.R.B. 269, Notice 2004-50, 2004-33 I.R.B. 196, Pub. 969, Health Savings Accounts and Other Tax-Favored Health Plans, and other IRS published guidance.
Certain terms used in this Agreement, which are not defined elsewhere herein, shall have the following meanings:
- “Agreement” means this Health Savings Account Custodial Agreement and Acressa Insurance Disclosures, including all provisions set forth under the headings of “Health Savings Account Custodial Agreement,” “Health Savings Account Deposit Agreement,” “Health Savings Account Truth in Savings Disclosure,” “Health Savings Account Funds Availability Disclosure Agreement,” “Health Savings Account External Funds Transfer Agreement,” and “Health Savings Account Disclosure Statement,” as any of the foregoing may be amended from time to time.
- “Archer MSA” means an Archer Medical Savings Account, as defined in Code Section 220(d).
- “Beneficiary” means the beneficiary or beneficiaries named by the Account Owner to receive the funds remaining in the Account upon the Account Owner’s death.
- “Code” means the Internal Revenue Code of 1986, as amended or replaced from time to time, and any regulations thereto.
- “Dependent” means a dependent, as defined in Code Section 152 (determined) without regard to Code Sections 152(b)(1), (b)(2) and (d)(1)(B)), of the Account Owner.
- “Family Coverage” under an HDHP is coverage that is not Self-Only
- “HDHP” or “High Deductible Health Plan” means a plan described in Code Section 223(c)(2). (See Section A. of the Health Savings Account Disclosure Statement portion of this Agreement for more information regarding when an insurance plan qualifies as an HDHP under Code Section 223(c)(2)).
- “HSA” or “Health Savings Account” means a health savings account, as defined in Code Section 223(d).
- “IRS” means the Internal Revenue Service.
- “Qualified Medical Expenses,” as defined in Code Section 223(d)(2), means amounts paid for certain specified (but not all) expenses related to medical (See Section VII.B. of the Health Savings Account Disclosure Statement for further information regarding Qualified Medical Expenses.)
- “Rollover Contribution” or “Custodial Transfer” means a contribution of a distribution described in Code Sections 220(f)(5) or 223(f)(5) from an Archer MSA or an HSA, respectively, benefiting the Account If a Rollover Contribution occurs, then funds must be deposited into the Account within 60 days after the date of the distribution from the Archer MSA or HSA.
- “Self-Only Coverage” is coverage under an HDHP covering only the Account Owner and does not include Dependent or spousal coverage.
The Account Owner and Custodian make the following Agreement:
- Custodian will accept additional contributions for the tax year made by the Account Owner or on behalf of the Account Owner (by an employer, family member or any other person). No contributions will be knowingly accepted by Custodian for any Account Owner that exceed the maximum amount for Family Coverage plus the catch-up contribution.
- Contributions for any tax year may be made at any time before the deadline for filing the Account Owner’s federal income tax return for that year (without extensions).
- Rollover or Transfer Contributions from an HSA or an Archer MSA (unless prohibited under this Agreement) need not be in cash and are not subject to the maximum annual contribution limit set forth in Article II.
- Custodian reserves the right to require that Qualified HSA funding distributions from an individual retirement account (“IRA”) be completed in a trustee-to-trustee transfer and are subject to the maximum annual contribution limit set forth in Article II.
- For calendar year 2020, the maximum annual contribution limit for an Account Owner with Self-Only Coverage is $3,550, and for 2021, it is $3,600. For calendar year 2020, the maximum annual contribution limit for an Account Owner with Family Coverage is $7,100, and for 2021, it is $7,200. These limits are subject to cost-of- living adjustments after 2021.
- Contributions to Archer MSAs or other HSAs count toward the maximum annual contribution limit to this HSA.
- For calendar year 2009 and later years, an additional $1,000 catch up contribution may be made for an account owner who is at least age 55 or older and not enrolled in Medicare. Contributions in excess of the maximum annual contribution limit are subject to an excise tax. However, the catch-up contributions are not subject to an excise tax.
It is the responsibility of the Account Owner to determine whether contributions to this HSA have exceeded the maximum annual contribution limit described in Article II. If contributions to this HSA exceed the maximum annual contribution limit, the Account Owner shall notify Custodian that there exist excess contributions to the HSA. It is the responsibility of the Account Owner to request the withdrawal of the excess contributions and any net income attributable to such excess contributions.
The Account Owner’s interest in the balance in this custodial account is non-forfeitable.
- No part of the custodial funds in this Account may be invested in life insurance contracts or in collectibles as defined in Section 408(m) of the Code.
- The assets of this Account may not be commingled with other property except in a common trust fund or common investment fund.
- Neither the Account Owner nor Custodian will engage in any prohibited transaction with respect to this Account (such as borrowing against the Account or pledging the Account as collateral for a loan transaction or engaging in any other prohibited transaction as defined in Section 4975 of the Code).
- Distribution of funds from this HSA may be made upon the direction of the Account
- Distributions from this HSA that are used exclusively to pay or reimburse Qualified Medical Expenses of the Account Owner, his or her spouse, or Dependents are tax-free. However, distributions that are not used for Qualified Medical Expenses are included in the Account Owner’s gross income and are subject to an additional 20 percent tax on that amount. The additional 20 percent tax does not apply if the distribution is made after the Account Owner’s death, disability, or reaching age 65.
- Custodian is not required to determine whether the distribution is for the payment or reimbursement of Qualified Medical Only the Account Owner is responsible for substantiating that the distribution is for Qualified Medical Expenses and must maintain records sufficient to show, if required, that the distribution is tax-free.
If the Account Owner dies before the entire interest in the Account is distributed, the entire Account will be disposed of as follows:
- If the Beneficiary is the Account Owner’s spouse, the HSA will become the spouse’s HSA as of the date of death.
- If the Beneficiary is not the Account Owner’s spouse, the HSA will cease to be an HSA as of the date of death. If the Beneficiary is the Account Owner’s estate, the fair market value of the Account as of the date of death is taxable on the Account Owner’s final For other Beneficiaries, the fair market value of the Account is taxable to that person in the tax year that includes such date.
- If you desire to designate a former or estranged spouse as the Beneficiary of all or a portion of the funds in your Account, you must provide us with a Beneficiary designation form and a copy of valid divorce or separation agreement between you and your former or estranged spouse evidencing such designation.
- The Account Owner agrees to provide Custodian with information necessary for Custodian to prepare any report or return required by the IRS.
- Custodian agrees to prepare and submit any report or return as prescribed by the
Notwithstanding any other Article that may be added or incorporated in this Agreement, the provisions of Articles I through VIII and this sentence are controlling. Any additional Article or provision in this Agreement that is inconsistent with Section 223 of the Code or IRS published guidance will be void.
This Agreement will be amended from time to time to comply with the provisions of the Code or IRS published guidance. Other amendments may be made in accordance with Article XIV.
Except as hereinafter provided, the Account Owner hereby directs Custodian to invest contributions to the Account in an interest-bearing deposit account with a bank or similar depository institution.
- Subject to this Agreement, the Account Owner may enroll in a Self-Directed Investment feature allowing them to transfer funds from their HSA and invest those funds within a group of mutual funds registered under the Investment Company Act of As such, those funds transferred into a non-FDIC-insured mutual fund are subject to the restrictions as well as the terms and conditions provided to the Account Owner prior to their enrollment within the Self-Directed Investment feature. MUTUAL FUND INVESTMENTS ARE NOT FDIC- INSURED, MAY LOSE VALUE, AND HAVE NO BANK GUARANTEE. With respect to any Self Directed Investment feature, the Account Owner shall have exclusive responsibility for and control over the investment of assets. Custodian shall have no discretion to direct any funds allocated from the HSA to the Self Directed Investment feature, and Custodian shall not provide the Account Owner with investment advice or offer any opinion to the Account Owner with respect to the value or suitability of any investment or any purchase or sale of securities related to the Self Directed Investment feature.
- Indemnification, Limitation of Liability and Disclaimers
- The Account Owner hereby releases and agrees to indemnify, defend, and hold harmless Custodian, its parent company, affiliates, and subsidiaries, and their respective directors, officers, employees and agents (collectively, the “Custodian Indemnified Parties”), promptly after receipt of a request therefrom, from and against any and all claims, liabilities, obligations, losses, damages, penalties, actions, judgments, suits, proceedings, costs (including, without limitation, the fees and expenses of legal counsel to the Custodian Indemnified Parties), expenses, or disbursements of any kind or nature whatsoever and by whomsoever brought or caused (collectively, the “Indemnified Liabilities”) that may be imposed upon, incurred by, or asserted against the Custodian Indemnified Parties and that in any way relate to or arise out of: (i) your breach of this Agreement; (ii) your negligence, fraud, intentional misconduct or criminal acts; (iii) any action taken or omitted by Custodian in accordance with instructions or other communications authorized by or on behalf of you or that Custodian has a reasonable, good faith basis to believe to have been so authorized; (iv) any subpoena, order, levy, garnishment, or request related to the Account; or (v) any loss or claim arising from your failure to use or adhere to the Security Procedures.
- TO THE MAXIMUM EXTENT PERMITTED BY APPLICABLE LAW, CUSTODIAN’S LIABILITY TO YOU ARISING FROM OR RELATED IN ANY WAY TO THIS AGREEMENT (WHETHER BASED IN CONTRACT, TORT, OR ANY OTHER THEORY OF LIABILITY) SHALL BE LIMITED TO ACTUAL AND PROVEN DAMAGES ARISING DIRECTLY FROM CUSTODIAN’S WILLFUL MISCONDUCT OR GROSS NEGLIGENCE. OTHER THAN AS SET FORTH IN THE PREVIOUS SENTENCE OR AS OTHERWISE PROVIDED HEREIN, CUSTODIAN SHALL NOT INCUR ANY LIABILITY OF ANY NATURE IN CONNECTION WITH THE ACCOUNT.
- THE ACCOUNT, THE WEBSITE, AND ALL RELATED SERVICES AND DOCUMENTATION ARE PROVIDED BY CUSTODIAN ON “AS IS” BASIS, EXCEPT AS EXPRESSLY SET FORTH HEREIN, CUSTODIAN MAKES NOT REPRESENATIONS OR WARRANTIES OF ANY NATURE WITH RESPECT TO THE ACCOUNT, THE WEBSITE, OR ANY RELATED SERVICES AND DOCUMENTIATON, THAT YOUR USE THEREFORE WILL BE ERROR-FREE OR THAT CUSTODIAN’S OPERATIONS WILL BE UNINTERRUPED. FURTHER, CUSTODIAN HEREBY DISCLAIMS ALLLABILITY THERETO AND EXPRESSLY DISCLAIMS ANY IMPLIED WARRANTY OF MERCHANTABILITY, FITNESS FOR A SPECIFIC PURPOSE, INFRINGEMENT OR OTHER IMPLED CONTRACTUAL WARRANTY, AND YOU HEREBY AGREE AND ACKNOWLEDGE THAT CUSTODIAN SHALL HAVE NO LIABILTY TO YOU WHATSOEVER FOR ANY OF THE MATTERS SET FORTH IN THIS SECTION.
- Change of Address. Account Owner shall notify Custodian of any change of Such change shall be effective upon the receipt of the change of address authorization.
- Termination by the Account Owner. The Account Owner shall have the right to terminate this Account. The Account Owner shall appoint a successor custodian or trustee authorized to act as such in relation to HSAs under the As soon as is practicable following written notice of this appointment, Custodian shall transfer all assets and appropriate records of the Account to the successor custodian or trustee. Custodian shall not be liable for any actions or failures to act on the part of any successor custodian or trustee, nor for any tax consequences the Account Owner may incur resulting from any transfer or distribution.
- Termination by Custodian. Custodian may resign and terminate this Agreement at any time upon thirty (30) days written notice to the Account Owner and shall turn over to the successor custodian or trustee all assets and appropriate records of the Account. Custodian shall not be liable for the acts or omissions of any successor custodian or trustee. If the Account Owner does not name a successor custodian or trustee within thirty (30) days after written notice of Custodian’s resignation, Custodian may appoint a successor custodian for the Account. After Custodian has transferred the assets of the Account in connection with the termination of the Account, it shall be relieved of all further liability with respect to the Account.
- Investments. Except as otherwise provided in Article XI, Section 2 of this Agreement, Custodian shall receive and invest contributions, and shall hold and distribute assets and investments of the Account pursuant to the directions of the Account Owner. Custodian shall keep records of its administration of the Account, and of all investments, receipts of funds, and disbursements and other transactions involving the Account.
- Reporting. Custodian shall furnish a report to the Account Owner concerning the status of the Account at least once annually, or more often if required by law. The Account Owner agrees that these reports will be sufficient to comply with the rules and regulations regarding confirmation requirements for securities transactions, including transactions in mutual funds, and directs Custodian not to send notification of each individual transaction. The Account Owner has been informed that the Account Owner has the right to receive individual confirmations for each securities transaction at no additional cost to the Account Owner, and he or she hereby waives that right and authorizes Custodian to instead provide information on securities transactions in periodic account statements for the period involved in the form regularly used by Custodian for such statements.
- Tax Effect. Custodian shall have no responsibility for determining the tax effect of contributions to the Account by, or on behalf of, the Account Owner. Likewise, Custodian shall have no responsibility for determining the tax effect of distributions from the Account to, or on behalf of, the Account Owner.
- Defense of Legal Action. Custodian shall not be obligated to commence or defend any legal action or proceeding in connection with the Account unless agreed upon by Custodian and the Account Owner or their legal representatives.
- Additional Powers and Rights of Custodian. Custodian shall have the following powers and rights in addition to those stated elsewhere and/or granted by law: to pay any tax attributable to any asset of the Account or any benefit or distribution paid from the Account; prior to release of any asset or distribution from the Account, Custodian may require a release or similar document from the applicable taxing authority in order to protect itself from possible tax liability; to employ suitable agents and counsel; to perform any and all acts it deems necessary to effect the proper management of the Account; and to begin, maintain, or defend any litigation necessary in connection with the administration of the Account, provided however that Custodian shall not be required to do so unless fully indemnified to its satisfaction pursuant to Article XII, Section 1 of this Agreement,
- Custodian may resign and terminate this Agreement at any time upon 30 days written notice to the Account Owner and shall turn over to the successor custodian or trustee all assets and appropriate records of the Account. Custodian shall not be liable for the acts or omissions of any successor custodian or trustee. If the Account Owner does not name a successor custodian or trustee within 30 days after written notice of Custodian’s resignation, Custodian may appoint a successor custodian for the
- Custodian shall have the right, power and authority to do each and every act and thing and to enter into and carry out each and every agreement with respect to the Account which may be necessary or advisable to discharge its responsibilities under this
- Website and Security Procedures.
- Custodian may grant the Account Owner online access to the Account through Custodian’s website (the “Website”). The Website may be made available for view access only or to allow the Account Owner to execute certain other services online. Custodian does not guarantee and is not liable for the performance, security or privacy of the Website or the Account Owner’s ability to access the Website. Custodian may use a third-party service provider to establish, design, maintain and provide access, connectivity and related services through multiple interfaces of the Website. Such interfaces together with the Website shall be controlled by Custodian and remain subject to the terms and conditions of this Agreement and applicable law.
- Your access to the Website is subject to Custodian’s security procedures, which may include the use of out of band identification codes, multi-factor authentication, unique login identifications, confidential passwords, call back verifications, and dual control procedures (collectively, the “Security Procedures”). Each time you make access the Website, you warrant that the Security Procedures are commercially reasonable. We are not under any circumstance liable for the unavailability of access to the Website or data entry errors and other errors made by the Account Holder when using the Website. We may, in our discretion, use additional procedures to verify the authenticity of your access credentials or a request for any services related to the Account. We are not responsible for our refusal to act upon any instruction received by us that does not comply with the Security Procedures, including where our reasonable efforts to verify instructions in accordance with the Security Procedures have failed or where action is delayed until such verification can be obtained. We reserve the right to issue new Security Procedures and/or cancel or change any Security Procedure from time to time. You understand that the Security Procedures are not designed for the detection of errors in the transmission or content from you to Custodian and that Custodian is not obligated to detect errors, even if it takes action from time to time to do so. No procedure for the detection of errors has been agreed upon between the Account Owner and Custodian, and you are solely liable for such errors. IN THE EVENT YOU DECLINE TO USE OR FAIL TO USE THE SECURITY PROCEDURES AS INSTRUCTED, CUSTODIAN DISCLAIMS ALL LIABILITY FOR ANY RESULTING LOSSES WHICH COULD HAVE BEEN PREVENTED BY YOUR USE OF THE SECURITY PROCEDURES.
- Privacy. The Account is subject to the privacy and security protections of the Gramm-Leach-Billey Act. Custodian has policies and procedures in place designed to maintain the confidentiality of the Account Owner’s personal information. Custodian collects, processes, discloses, and safeguards such personal information in accordance with its privacy notice and policy, which can be viewed on the Website. All personal information furnished by Account Owner in connection with the Account is subject to Custodian’s privacy notice and policy. With respect to any data breach or security incident, Custodian will comply with notification requirements and data breach procedures required by state and federal law and as set forth in its privacy notice and policy.
- Tax Matters. This HSA Custodial Agreement includes and is intended to be the Internal Revenue Service’s model custodial account agreement (IRS Form 5305-C). Certain additions have been made in accordance with Article XI of the model agreement and have been drafted with the intention that they comply with the provisions of Section 223 of the Code and any regulations thereunder. However, the tax consequences of the establishment of an Account under this Agreement, and the contributions to and distributions from the Account, are the responsibility of the Account Owner and the Account Owner’s tax and legal advisors.
- Successor Custodian. If Custodian reorganizes, mergers with another organization (or comes under the control of any federal or state agency), or if Custodian’s entire business organization or any portion thereof is acquired by another organization, the surviving organization shall automatically become the trustee or custodian under the Code and applicable law (the “Successor Custodian”). Custodian shall provide the Account Owner with notice of any event resulting in a Successor Custodian. If the Owner does not close or complete a transfer of the Account within thirty (30) days from the date of Custodian’s notice, Custodian will transfer the Account assets to the Successor Custodian without further notice.
- Securities Disclosure. Unless the Account Owner has expressly objected to the disclosure of such information, pursuant to Securities and Exchange Commission Rule 14b-2 promulgated under the Securities Exchange Act of 1934, as amended, Custodian is required to disclose the following information to each issuer of securities held under this Agreement from time to time: the Account Owner’s name, address and holdings of securities of that To object to and prevent such disclosure under Rule 14b-2, the Account Owner must notify Custodian in writing.
- Restrictions on Distribution. Notwithstanding Article VI, distribution of funds from the Account may be subject to reasonable restrictions on frequency or minimum amounts established by Custodian and communicated in advance to the Account Owner in the Health Savings Account Deposit Agreement or elsewhere in this Agreement.
- Mistake. The Account Owner may repay to the Account any amount distributed from the Account because of a mistake of fact due to reasonable cause that an expense paid or reimbursed by the Account was a Qualified Medical Expense, by no later than April 15 of the year following the year the Account Owner knew or should have known the distribution was a Custodian may rely on the Account Owner’s representation that the distribution was a mistake that qualifies for a return as provided herein.
- Rollover Contribution. Notwithstanding Article I, Custodian may require the Account Owner to furnish written evidence that any property comprising all or part of any Rollover Contribution qualifies as a “rollover contribution” as defined under Code Section 223 prior to accepting the contribution as a
- Notice and Consent to Electronic Disclosures. Any notice provided for in this Agreement shall be effective when Custodian sends it to the Account Owner at the Account Owner’s last known address in Custodian’s records or posts it in electronic form to the Website. The Account Owner consents to and agrees that all notices, disclosures, documentation and other information related to the Account may be made available by Custodian, at Custodian’s discretion, to Account Owner via first class mail or electronically through the Website and/or delivered to the Account Owner via email, and such notices, documentation, and other information related to the Account will be considered delivered when so made available or delivered. Any notice to be given to Custodian must be delivered via first class mail to: 2508 Highlander Way, Suite 200, Carrollton, TX 75006. And shall be considered effective when Custodian received it. The Account Owner is responsible to advise the Custodian in writing of any change to its email or mailing address of records.
- Governing Law, Jurisdiction and Venue. This Agreement shall be governed by federal law and regulations, and to the extent applicable, the laws of the State of Arizona, without regards to the conflict of law principles thereof. If for any reason a dispute arises, the Account Owner hereby (i) irrevocably and unconditionally consent to the jurisdiction of the state courts of the State of Arizona located in Maricopa County and the federal courts of the United States of America located therein and (ii) agrees that any action or proceeding in respect of any claim arising out of or related in any way to this Agreement or the Account shall be brought exclusively in a court of competent jurisdiction located therein.
- Entire Agreement; Invalidity; Waiver; Benefit. If any part of this Agreement is held to be illegal or invalid, the remaining parts shall not be affected. Neither the Account Owner’s nor the Custodian’s failure to enforce at any time or for any period any of the provisions of this Agreement shall be construed as a waiver of such provisions. The Account shall be maintained for the exclusive benefit of the Account Owner or his or her Beneficiaries and may not be attached or alienated, unless permitted by law.
- Legal Process.
- If Custodian is served with a subpoena, warrant, request, levy, order, or garnishment request from a governmental authority, court or tribunal for information or records concerning the Account or you, Custodian will follow the advice of its legal counsel as to the appropriate response to such subpoena, warrant, request, levy, order or garnishment, and shall have no liability or responsibility whatsoever to you for doing so even if such advice shall turn out to have been mistaken. You acknowledge and agree that Custodian’s current policy (which is subject to change based on advice of legal counsel) is to comply with any such subpoena, warrant, request, levy, order or garnishment, as concerns information, records or funds.
- If you are served with a subpoena, warrant, order, or other request from a governmental authority, court or tribunal for information or records concerning the Account or Custodian, you will provide Custodian with prompt written notice so that Custodian may seek a protective order or other appropriate remedy. If, in the absence of a protective order or other remedy or Custodian’s waiver, you are nonetheless legally compelled to disclose such requested information, you may, without liability hereunder, disclose only that portion of such information that your counsel advises you are legally required to disclose, provided that you shall use your best efforts to preserve the confidentiality of any information, including, without limitation, by cooperating with Custodian to obtain an appropriate protective order or other reliable assurance of confidential treatment by the governmental authority, court, or tribunal.
- Assignment. Custodian reserves the right to assign this Agreement without your prior consent, provided that any assignee must be qualified under the Code to be an HSA custodian or trustee. Upon assignment of this Agreement, the assignee shall automatically become custodian of the Account. Custodian shall not be liable for any actions or failures to act neither on the part of any successor custodian or trustee, nor for any tax consequences that result from the transfer or distribution of the Accounts’ assets.
- Amendment. Custodian shall have the right to amend or modify this Agreement at any time, including retroactively, to comply with the requirements of the Code and applicable law. Any material amendments, with materiality to be determined in the sole discretion of Custodian, shall require the Account Owner’s consent, by action or no action, and will be preceded by at least 30 days’ advanced written notice to the Account Owner, specifying the amendment and the proposed effective date. Unless otherwise required by law, the Account Owner is deemed to automatically consent to an amendment by continuing to maintain the Account after Custodian has sent notice of an amendment, which means that the Account Owner’s written approval is not required for the amendment to apply to the Account. In that event that the Account Owner objects to the amendment by provided Custodian notice thereof in writing prior to the expiration of the 30-day period, Custodian will close the Account and the account balance, less any outstanding fees, will be transferred to a custodian or trustee qualified under the Code and application law or, at Account Owner’s election, distributed to the Account Owner.
- Acknowledgement of the Agreement. The Account Owner acknowledges that he or she has received and read this Agreement. As such, the Account Owner agrees to all terms of this Agreement, and further agrees that the information in the Account Owner’s Health Savings Account Application is true and accurate as of the date thereof.
You acknowledge that you have read and or printed a copy of this Health Savings Custodial Agreement and agree to abide by the terms of that Agreement.
HEALTH SAVINGS ACCOUNT DEPOSIT AGREEMENT
The terms “you” and “your” refer to the Account Owner, the term “Depository” refers to the depository institution into which your HSA funds are deposited as set forth herein, and the terms “we”, “us” and “our” refer to Custodian. You understand that this Health Savings Account Deposit Agreement (“Deposit Agreement”) governs your deposit account (the “Account”) with a depository institution (“Depository”), along with any other documents applicable to your Deposit Account, including the attached Truth in Savings Account Disclosure (“Disclosures”), which are incorporated herein by reference. You understand that your Account is also governed by applicable law.
YOUR RELATIONSHIP WITH US – CUSTODIAL RELATIONSHIP
As Custodian for your HSA, we will place your funds into a deposit account at a Depository selected by us in our sole discretion. Depository may be any depository institution. The Account will be recorded on the records of Depository in our name as Custodian.
While we are acting as Custodian for your HSA, all contributions to your HSA (made by you, your employer, a family member or any other person) will be made to us, and we will deposit the funds into your Account. We will disburse funds from the Account pursuant to your Deposit Agreement with us.
You may not transfer the Account directly to another Depository. At your election, you may dismiss us as Custodian in accordance with the terms of the Custodial Agreement, and appoint a successor custodian authorized to act as such in relation to HSAs under the Code and applicable law. As soon as is practicable following written notice of the appointment of such a successor custodian, we will cause the funds in the Account to be transferred the successor trustee or custodian as soon as is practicable. Upon transfer of the Account to a successor trustee or custodian, the successor trustee or custodian shall automatically become custodian of the Account and we shall have no liability from any actions or failures to act following the transfer, either on the part of any successor custodian or trustee for any tax consequences that result from the transfer of the account or the funds therein.
TERMS AND CONDITIONS
- Deposit Deposits may be made in person, electronically or by mail. Depository is not responsible for transactions mailed until Depository actually receives and records them. Depository may, in Depository’s sole discretion, refuse to accept particular instruments as deposits. Cash deposits are credited to your account according to this Deposit Agreement. Other items you deposit are handled by Depository according to Depository’s usual collection practices. If an item you deposited is returned unpaid, Depository will debit your Deposit Account and adjust any interest earned. You are liable to us for the amount of any check or electronic transaction deposited into your Account that is returned, and all related costs and expenses related to the collection of some or the entire amount from you. Funds deposited to your Account are available in accordance with the Disclosures.
- Compliance With Applicable Laws.
- You use of the Account is subject to your compliance with all applicable laws, which includes, but is not limited to: (i) all applicable rules, regulations, requirements, guidelines, and commentaries issued by any state or federal governmental authority with jurisdiction over the Account, Custodian, of Depository; (ii) the federal Bank Secrecy Act and related Anti-Money Laundering laws and regulations; (iii) applicable sections of the USA PATRIOT Act, implementing regulations related to Know-Your-Customer and Customer Identification Programs; and (iv) Article 4A of the Uniform Commercial Code as currently in effect.
- Before you may use the Account, Custodian and/or Depository are required to obtain, verify, and record certain information provided by your for customer due diligence and identification purposes, including the you name, address, taxpayer identification number, and date of birth. Until this information has been verified pursuant to applicable laws, the Account may not be used. During such time, Custodian may charge its customary fees for maintaining the Account; provided that upon request from the Account Owner, Custodian will close the Account and return funds to the original contributor.
- Collection of Deposited Items. In receiving items for deposit or collection, Depository acts only as your agent and assumes no responsibility beyond the exercise of ordinary care. All items are credited subject to final settlement in cash or credits. Depository shall have the right to forward items to correspondents including all Federal Reserve Banks, and Depository shall not be liable for default or neglect of said correspondents for loss in transit, nor shall any correspondent be liable except for its own negligence. You specifically authorize Depository and Depository’s correspondents to utilize Federal Reserve Banks to handle such items in accordance with provisions of Regulation J (12 CFR Part 210), as revised or amended from time to time by the Board of Governors of the Federal Reserve System. In the event Depository is subject to local clearinghouse rules, you specifically authorize Depository to handle such items in accordance with the rules and regulations of the clearinghouse.
If Depository permits you to withdraw funds from your Deposit Account before final settlement has been made for any deposited item, and final settlement is not made, Depository has the right to charge your Deposit Account or obtain a refund from you.
In addition, Depository may charge back any deposited item at any time before final settlement for whatever reason. Depository shall not be liable for any damages resulting from the exercise of these rights. Except as may be attributable to Depository’s lack of good faith or failure to exercise ordinary care, Depository will not be liable for dishonor resulting from any reversal of credit, return of deposited items or for any damages resulting from any of those actions.
- Deposits will be available for withdrawal consistent with the terms of the Disclosures. Withdrawals may be subject to a service charge. Depository has the right to require seven days prior written notice from you of your intent to withdraw any funds from your account. Withdrawals may be subject to a service charge.
- Set-offs. Depository may set-off funds in your Deposit Account and any other accounts held by you, jointly or individually, to pay any debt you may owe Depository or Custodian. If the Deposit Account(s) is/are held jointly, Depository may offset funds for the debt of any one of the joint owners.
- Claims. In response to any garnishment, attachment, restraining order, injunction, levy, citation to discover assets, judgment, reclamation, other order of court or other legal process (“Claim(s)”), Depository has the right to place a hold on, remove from your Deposit Account(s) and/or remit to the designated third-party(ies) any amount on deposit in your Deposit Account as set forth in and required by such Claim(s). If the Deposit Account(s) is/are held jointly, Depository may place the hold, remove from the Deposit Account(s) and/or remit the amounts from the Deposit Account(s) arising from any Claim(s) relating to any one or more of the account holders. In addition, Depository may charge against your Deposit Account(s) any fee authorized by law in connection with the Claim(s) or as otherwise set forth in the Disclosures.
- You agree to be liable to Depository or Custodian for any loss, cost or expense that Depositor or Custodian incurs as a result of any dispute involving your Deposit Account, including reasonable attorneys’ fees to the extent permitted by law, and you authorize Depository to deduct such loss, cost or expense from your Deposit Account without prior notice to you.
- Dormant Accounts. You understand that if your Deposit Account is dormant, you may be charged the fee specified in the Disclosures and Depository may stop paying interest to the extent permitted by law. You understand that your Deposit Account balance may be escheated (that is, turned over to the state) in accordance with state law. Custodian’s general policy is that dormant Deposit Accounts are designated to Depository for escheatment after a dormancy period of three years. However, please be aware that each state has its own dormancy period and shorter or longer dormancy periods may apply depending on your state of residence. Depository will send prior notice to your address of record if your Deposit Account has been designated for escheatment. The notice to you will provide you with a cure period and may explain what actions you may take to keep your Deposit Account open. When a Deposit Account is escheated, Depository will close the Deposit Account and the funds will subsequently be escheated to the state of residence on file for you. Once the funds in your Deposit Account are escheated, you may be able to recover the funds from the state. You understand and agree that neither Depository nor Custodian are responsible to you for any funds that are escheated to a state.
- Joint Accounts, Trust Accounts and Custodial Accounts. You acknowledge, it is your sole responsibility to determine the legal effects of opening and maintaining a Deposit Account designated as a Joint Account, a Trust Account, or a Custodial Account.
- In Trust For Account. If the Deposit Account is designated as an In Trust For account, you may change the named beneficiary at any time by written direction to Custodian. Upon your death, or if there are two or more trustees, upon the death of the last trustee, the amount then on deposit together with the interest may be paid to the beneficiary or to the beneficiary’s legal representative. Depository will not release any funds, however, until all legal documents have been delivered to Depository. Depository will not be liable for any payments or withdrawals made in accordance with state law.
- Custodial Account. A custodial account is subject to applicable law as adopted by the state in which the account is opened. The documents that authorize the custodianship may be required for the account.
- Beneficiary Designation. Where a specific beneficiary designation for the Deposit Account is made to a person other than your current spouse, a written and executed spousal waiver or consent will be needed for Custodian to effect the designation.
- Power of Attorney. If you wish to name another person to act as your attorney in fact or agent in connection with your Deposit Account, you must obtain the prior written approval of Depository and Custodian for the form of appointment. Neither Depository nor Custodian has any duty to determine the validity of such appointments or any instrument appointing your attorneys-in-fact or agents. Neither Depository nor Custodian shall be responsible for losses of any kind that may result from directions, actions, omissions or failures to act by your attorney-in-fact or agent, and you agree to reimburse Depository and/or Custodian for any losses they may respectively incur as a result of such directions, actions, omissions or failures to act by your attorney in fact or agent.
- Fees, Service Charges and Balance Requirements. You agree you are responsible for any fees, charges, balance, or deposit requirements as stated in the Disclosures. Depository also reserves the right to impose a service charge for cashing checks drawn on your Deposit Account if the person cashing the check is not a customer of Depository. Schedule of Feeds attached hereto. If your Deposit Account balance is $0 or less for 12 consecutive months, Custodian may, at its discretion, direct Depository to close the deposit Account upon 30 days prior written notice to you.
- Amendments and Alterations. You agree that the terms and conditions governing your Deposit Account may be amended by Depository or Custodian from time to time. Depository or Custodian will notify you of amendments as required by applicable law. Your continued use of the Deposit Account evidences your agreement to any amendments. Notices will be sent to the most recent address shown on the Account records. Only one notice will be given in the case of joint account holders.
- You are responsible for notifying Custodian of any address or name changes, the death of an account holder or other information affecting your Deposit Account. Notices must be in a form and manner acceptable to Custodian with enough information to allow Custodian to identify the Account. Notice sent by you to us is not effective until Depository has received it and has a reasonable opportunity to act on it. Written notice sent by Depository or Custodian to you is effective when mailed to the last address supplied to Custodian.
- Closing Account. Depository may close your Deposit Account at any time, with or without cause, by sending you notice and a check for the balance in Depository’s possession to which you may be entitled. At Depository’s discretion, Depository has the authority to pay an otherwise properly payable check, which is presented after the closing of your Deposit Account.
- Transfers and Assignments. You cannot assign or transfer any interest in your Deposit Account unless Custodian and Depository both agree in writing.
- Applicable Laws and Regulations. This Deposit Agreement shall be governed by federal law and regulations and to the extent applicable, the laws of the State of Arizona, provided, however, your rights to the Deposit Account may be governed by the laws of the state in which the Deposit Account is opened, unless federal law controls. Changes in these laws may change the terms and conditions of your Deposit Account. Custodian will notify you of any changes as required by law.
- ACH and Wire Transfers. Fund transfers from the Deposit Account shall bes subject to Article 4A of the Uniform Commercial Code as adopted by the state in which the Deposit Account is opened. If you send or receive a wire transfer, you agree that Fedwire ® Funds Service may be used. Regulation J of the Board of Governors of the Federal Reserve System is the law that covers transactions made over Fedwire ® Funds Service. When you originate a funds transfer for which Fedwire ® Funds Service is used, and you identify by name and number a beneficiary financial institution, an intermediary financial institution or a beneficiary, Custodian, Depository and every receiving or beneficiary institution may rely on the identifying number to make payment. Custodian and Depository may rely on the number even if it identifies a financial institution, person or account other than the one named. If you are a party to an Automated Clearing House (“ACH”) entry, you agree to be bound by the Operating Rules and Guidelines of the National Automated Clearing House Association (“NACHA”), the rules of any local ACH operator, and the rules of any other system through which the entry is made.
- Provisional Payment. Any credit Depository gives you with respect to an ACH credit entry is provisional until Depository receives final settlement for that entry through a Federal Reserve Bank. If Depository does not receive final settlement with respect to such credit, you agree that Depository is entitled to a refund of the amount credited to you in connection with the entry, and the party making the payment to you via such entry (i.e., the originator of the entry) shall not be deemed to have paid you in the amount of such entry.
- International ACH Transactions. If any transactions related to your Deposit Account originates from a financial institution that is outside of the territorial jurisdiction of the United States, it may be subject to additional review for compliance with the rules of the Office of Foreign Assets Control (OFAC). If additional review is required, the international ACH transaction will not be available to you until it passes final verification.
- Notice of Receipt. Under the Operating Rules and Guidelines of NACHA, which are applicable to ACH transactions involving your Deposit Account, Depository and Custodian are not required to give next day notice to you of receipt of an ACH entry and Depository and Custodian will not do so. However, Depository and Custodian will continue to notify you of the receipt of payments in the periodic statements Custodian provides to you.
- NACHA Compliance. Depository may accept on your behalf payments to your Deposit Account which have been transmitted through one or more ACH operators and which are not subject to the Electronic Fund Transfer Act, and your rights and obligations with respect to such payments shall be construed in accordance with and governed by the Operating Rules and Guidelines of NACHA.
- Payment of Interest. If this is an interest bearing account, the interest is calculated and paid in accordance with the Disclosures.
- Checks. All negotiable paper (“checks”) presented for deposit must be in a format that can be processed and Depository may refuse to accept any check that does not meet this requirement. All endorsements on the reverse side of any check deposited into your Deposit Account or on any check issued by you must be placed on the left side of the check when looking at it from the front, and must be placed so as to not go beyond an area located 1.5 inches from the left edge of the check when looking at it from the front. It is your responsibility to ensure that this requirement is met and you are responsible for any loss incurred by Depository for failure of an endorsement to meet this requirement.
- Substitute Checks. To make check processing faster, federal law permits financial institutions to replace original checks with “substitute checks.” These checks are similar in size to original checks with a slightly reduced image of the front and back of the original check. The front of a substitute check states: “This is a legal copy of your check. You can use it the same way you would use the original check.” You may use a substitute check as proof of payment just like the original check. Some or all of the checks that you receive back from Depository may be substitute check(s).
- Non-Sufficient Funds. If your Deposit Account lacks sufficient available funds to pay a check, preauthorized transfer, or other debit activity presented for payment, Depository may return such item for non-sufficient funds and will charge you a fee as provided in the Disclosures. Depository’s processing order is: All credit transactions are processed first. Debits, or withdrawals, from your Deposit Account will be processed as follows: electronic items such as ATM and Pre-Authorized transactions then checks. The items are processed in the order received within each category.
- Stop Payments. If you request Depository to stop payment on a check you have written, or on a preauthorized transfer, you will give written or other confirmation as allowed by Depository within 14 days of making the request. If you fail to confirm an oral stop payment request within the 14 days, Depository reserves the right to cancel the request. Requests to stop all future payments on a preauthorized transfer may require additional documentation to be supplied to Depository. Your stop payment request must describe the item or account with reasonable certainty, and Depository must receive the request in a time and way that gives Depository a reasonable opportunity to act on it. A stop payment on a check you have written will remain in effect for 6 months or until Depository receives written revocation of the stop payment, whichever occurs first. A stop payment on a preauthorized transfer will remain in effect until Depository receives a withdrawal of the stop payment request or the return of the debit entry(ies), whichever occurs first. You understand that Depository may accept the stop payment request from any of the joint owners of the account, regardless of who signed the check or authorized the transfer. Depository’s acceptance of a stop payment request does not constitute a representation by Depository that the item has not already been paid or that Depository has had a reasonable opportunity to act on the request. Depository may accept a stop payment request on lost or stolen checks, whether a single check or a series, unless Depository’s policy requires that Depository open a new account for you to ensure your security.
- Statements. Custodian will provide you with a periodic statement showing the Deposit Account activity, either by email, mail or posted to Custodian’s website. The Account Owner who receives this statement is the agent for his/her co- account holder(s) for purposes of receiving the statement and items. You must notify Custodian within 30 days after Custodian mails or otherwise make the statement available to you of any discrepancies. If you fail to notify Custodian, you will have no claim against Depository. However, if the discrepancy is the result of an electronic fund transfer, the provisions of the Disclosures will control its resolution. If you do not receive a statement from Custodian because you have failed to claim it or have supplied Custodian with an incorrect mail or email address, Custodian may stop sending your statements until you specifically make written request that Custodian resume sending your statements and you supply Custodian with a valid address.
- Stale or Postdated Checks. Depository reserves the right to pay or dishonor a check more than 6 months old without prior notice to you. If you can write checks on your Deposit Account, you agree not to postdate any check drawn on the Deposit Account. If you do and the check is presented for payment before the date of the check, Depository may pay it or return it unpaid. Depository is not liable to you for paying any stale or postdated check, and you agree to reimburse Depository for any loss Depository might suffer, as long as Depository acted in good faith or exercised ordinary care. Any damages that you incur, and which Depository may be liable for, are limited to actual damages not to exceed the amount of the check.
- Check Safekeeping. If you utilize a check safekeeping or any other system offered by Depository for the retention of your checks, you understand that the canceled checks will be retained by Depository and destroyed after a reasonable time period or as required by law. At your request, Depository will provide without charge up to 25 canceled instruments or legible copies of the fronts and backs thereof per calendar year. Additional copies may be subject to a fee, as indicated in the Schedule of Fees or Disclosures. If for any reason Depository cannot provide you with a copy of a check, Depository’s liability will be limited to the lesser of the face amount of the check or the actual damages sustained by you.
- Facsimile Signatures. You authorize Depository, at any time, to charge you for all checks, drafts, or other orders for the payment of money, that are drawn on Depository regardless of by whom or by what means the facsimile signature(s) may have been affixed so long as they resemble the facsimile signature specimen in our files and contain the required number of signatures for this purpose.
- Restrictive Legends. Depository is not required to honor any restrictive legend on checks you write unless Depository has agreed to the restriction in a writing signed by an officer of Depository.
- No Waiver. You understand and agree that no delay or failure on Depository’s part to exercise any right, remedy, power or privilege available to Depository under this Agreement shall affect or preclude Depository’s future exercise of that right, remedy, power or privilege.
- Negative Balances. According to the Internal Revenue Code Section 4975, if an HSA transaction results in a negative balance, the HSA will cease to be an HSA on the first day of the year in which the prohibited transaction occurred. The account will be closed.
I acknowledge that:
I have provided my correct taxpayer identification number (or I am waiting for a number to be issued to me), and
I am not subject to backup withholding because: (a) I am exempt from backup withholding, or (b) I have not been notified by the Internal Revenue Service (IRS) that I am subject to backup withholding as a result of a failure to report all interest or dividends, or (c) the IRS has notified me that I am no longer subject to backup withholding; and
I am a U.S. citizen or legal resident of the U.S.; and
You have read and or printed a copy of this Deposit Agreement and agree to abide by the terms of this Deposit Agreement.
All signers authorize Custodian and Depository to make inquiries from any consumer reporting agency, including a check protection service, in connection with the Account and the Deposit Account.
HEALTH SAVINGS ACCOUNT FEE DISCLOSURE
Custodian reserves the right to charge the below fees:
FEES AND CHARGES
|Trustee to Trustee transfer or Rollover (outgoing)
|Non-sufficient funds (NSF)(can be created by check or other electronic means)
|Periodic paper statement
||Up to a $1.95
|**Paper statement fee charged periodically – Please note you may opt in to receive free electronic statements online by choosing HSA statements and setting your preference.
Deposit Accounts cannot be transferred without consent from Custodian. We reserve the right to require at least seven days written notice before any withdrawal or transfer.
You acknowledge that you have read and or printed a copy of this Fee Disclosure and agree to abide by the terms of such.