Common Contracts
2 similar Custodial Agreement contracts
Health Savings Account (HSA) Custodial Agreement and Disclosure StatementsCustodial Agreement • December 3rd, 2020
This Agreement is a contract between you and us regarding each party's rights and responsibilities with regard to your HSA. You are establishing this HSA, as defined in the Internal Revenue Code ("Code") Section 223(d), exclusively for the purpose of paying or reimbursing qualified medical expenses of you, your spouse, and your dependents. In addition to any other representations in this Agreement, you represent that, unless this HSA is used solely to make rollover contributions, you are eligible to contribute to this HSA; specifically, that you (i) are covered under a high deductible health plan ("HDHP"), (ii) are not also covered by any other health plan that is not an HDHP (with certain exceptions for plans providing preventive care and limited types of permitted insurance and permitted coverage), (iii) are not enrolled in Medicare, and (iv) cannot be claimed as a dependent on another person's tax return. By establishing an HSA in accordance with the terms of this Agreement, the par
Health Savings Account (HSA) Custodial Agreement and Disclosure StatementsCustodial Agreement • September 22nd, 2020
This Agreement is a contract between you and us regarding each party's rights and responsibilities with regard to your HSA. You are establishing this HSA, as defined in the Internal Revenue Code ("Code") Section 223(d), exclusively for the purpose of paying or reimbursing qualified medical expenses of you, your spouse, and your dependents. In addition to any other representations in this Agreement, you represent that, unless this HSA is used solely to make rollover contributions, you are eligible to contribute to this HSA; specifically, that you (i) are covered under a high deductible health plan ("HDHP"), (ii) are not also covered by any other health plan that is not an HDHP (with certain exceptions for plans providing preventive care and limited types of permitted insurance and permitted coverage), (iii) are not enrolled in Medicare, and (iv) cannot be claimed as a dependent on another person's tax return. By establishing an HSA in accordance with the terms of this Agreement, the par
