HEALTH SAVINGS CUSTODIAL ACCOUNT AGREEMENTHealth Savings Custodial Account Agreement • December 2nd, 2021
The account owner named on the application is establishing this health savings account (HSA) exclusively for the purpose of paying or reimbursing qualified medical expenses of the account owner, his or her spouse, and dependents. The account owner represents that, unless this account is used solely to make rollover contributions, 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 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.
HEALTH SAVINGS CUSTODIAL ACCOUNT AGREEMENTHealth Savings Custodial Account Agreement • October 21st, 2019
The account owner named on the application is establishing this health savings account (HSA) exclusively for the purpose of paying or reimbursing qualified medical expenses of the account owner, his or her spouse, and dependents. The account owner represents that, unless this account is used solely to make rollover contributions, 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 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.
Liferaft Health Savings Custodial Account AgreementHealth Savings Custodial Account Agreement • October 12th, 2021 • Virginia
Ridge Bank, N.A. (the “Bank”), the provider and custodian of the Account and a member of the Federal Deposit Insurance Corporation (“FDIC”).Liferaft Risk Technologies (“Program Partner”) is the program manager of the Account. When you see the words “we,” “us,” or “our” in this Agreement, it refers to the Bank, and any of the Bank’s affiliates, successors, assignees, agents or service providers. When you see the words “you” or “your,” it refers to you, the owner of the Account, as well as your personal representatives, executors, administrators, and successors.
HEALTH SAVINGS CUSTODIAL ACCOUNT AGREEMENTHealth Savings Custodial Account Agreement • September 26th, 2014 • Colorado
The Account Owner named on the HSA Application is establishing this Health Savings Account (HSA) exclusively for the purpose of paying or reimbursing Qualified Medical Expenses of the Account Owner, his or her spouse, and tax dependents. The Account Owner represents that unless this account is used solely to make rollover contributions, he or she is eligible to contribute to this HSA; specifically, that he or she: (1) is (or will be as of the effective date of this Agreement) 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 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.
Health Savings Custodial Account AgreementHealth Savings Custodial Account Agreement • July 1st, 2005 • California
This Custodial Agreement (“Agreement”) is made between Trust Administrators, Inc. (“TAI”) and the individual (“account owner”) who signs TAI’s HSA Enrollment Form. Account owner has designated TAI as custodian for their Health Savings Account (“HSA”) under Internal Revenue Code (“Code”) section 223(a). This Agreement is intended to comply with Form 5305-C drafted by the Internal Revenue Service (“IRS”).
