Common use of AGREEMENT AND DISCLOSURE Clause in Contracts

AGREEMENT AND DISCLOSURE. Participant represents and warrants that he/she has received, read and is in agreement with all terms in the FPS Terms and Conditions, the HSA Custodial Account Agreement, FPS’s privacy policy, the summary of fees and any applicable addendums to the Participant Agreement. Participant agrees to be bound by the terms of the Participant Agreement (including the terms of incorporated documents), which may be changed, from time to time, upon notice from FPS Trust. Participant appoints FPS Trust Company, LLC (“FPS”) as custodian for the HSA established by the HSA Enrollment and Agreement Form and authorizes FPS (including its affiliates) to perform relevant custodial and administrative services. Participant acknowledges Health Savings Administrators (including its affiliates) as record keeper of the HSA established by the HSA Enrollment and Agreement Form and authorizes Health Savings Administrators to perform relevant record keeping and administrative services. Participant understands and agrees that FPS may provide online access to the account through the issuance of usernames and passwords to Participant and other persons. Participant authorizes access to the account to the Authorized Signers, if any, listed. Further, FPS may provide usernames and passwords to Plan Administrators and/or other authorized persons/entities. Participant understands and agrees that persons/entities to which usernames and passwords are issued are solely responsible for the security of the username and password issued to him/her/it. FPS shall be entitled to rely on the entry of a username and password into FPS’s systems as confirmation of the identity of the person/entity to whom the username and password were issued. Asset based fees will be assessed on a quarterly billing cycle and will be assessed, pro rata, from the assets in the account. The administration fee will be assessed to the account annually. Participant understands and agrees that these fees may change, from time to time, upon notice from FPS. Participant understands and agrees that certain transaction fees may apply to the account. Participant understands and agrees that these fees may change, from time to time, upon notice from FPS. Participant authorizes and instructs FPS to assess referenced fees (and any other fees Participant may later agree to have assessed against the account) against the account registered in the Participant’s name established under this HSA Enrollment and Agreement Form.

AGREEMENT AND DISCLOSURE. Participant represents and warrants that he/she has received, read and is in agreement with all terms in the FPS Terms and Conditions, the HSA Custodial Account Agreement, FPS’s privacy policy, the summary of fees and any applicable addendums to the Participant Agreement. Participant agrees to be bound by the terms of the Participant Agreement (including the terms of incorporated documents), which may be changed, from time to time, upon notice from FPS Trust. Participant appoints FPS Trust Company, LLC (“FPS”) as custodian for the HSA established by the HSA Enrollment and Agreement Form and authorizes FPS (including its affiliates) to perform relevant custodial and administrative services. Participant acknowledges Health Savings Administrators (including its affiliates) as record keeper recordkeeper of the HSA established by the HSA Enrollment and Agreement Form and authorizes Health Savings Administrators to perform relevant record keeping recordkeeping and administrative services. Participant understands and agrees that FPS may provide online access to the account through the issuance of usernames and passwords to Participant and other persons. Participant authorizes access to the account to the Authorized Signers, if any, listed. Further, FPS may provide usernames and passwords to Plan Administrators and/or other authorized persons/entities. Participant understands and agrees that persons/entities to which usernames and passwords are issued are solely responsible for the security of the username and password issued to him/her/it. FPS shall be entitled to rely on the entry of a username and password into FPS’s systems as confirmation of the identity of the person/entity to whom the username and password were issued. Asset based fees will be assessed on a quarterly billing cycle and will be assessed, pro rata, from the assets in the account. The administration fee will be assessed to the account annually. Participant understands and agrees that these fees may change, from time to time, upon notice from FPS. Participant understands and agrees that certain transaction fees may apply to the account. Participant understands and agrees that these fees may change, from time to time, upon notice from FPS. Participant authorizes and instructs FPS to assess referenced fees (and any other fees Participant may later agree to have assessed against the account) against the account registered in the Participant’s name established under this HSA Enrollment and Agreement Form.

AGREEMENT AND DISCLOSURE. Participant represents and warrants that he/she has received, read and is in agreement with all terms in the FPS Terms and Conditions, the HSA Custodial Account Agreement, FPS’s privacy policy, the summary of fees and any applicable addendums to the Participant Agreement. Participant agrees to be bound by the terms of the Participant Agreement (including the terms of incorporated documents), which may be changed, from time to time, upon notice from FPS Trust. Participant appoints FPS Trust Company, LLC (“FPS”) as custodian for the HSA established by the HSA Enrollment and Agreement Form and authorizes FPS (including its affiliates) to perform relevant custodial and administrative services. Participant acknowledges Health Savings Administrators (including its affiliates) as record keeper recordkeeper of the HSA established by the HSA Enrollment and Agreement Form and authorizes Health Savings Administrators to perform relevant record keeping recordkeeping and administrative services. Participant understands and agrees that FPS may provide online access to the account through the issuance of usernames and passwords to Participant and other persons. Participant authorizes access to the account to the Authorized Signers, if any, listed. Further, FPS may provide usernames and passwords to Plan Administrators and/or other authorized persons/entities. Participant understands and agrees that persons/entities to which usernames and passwords are issued are solely responsible for the security of the username and password issued to him/her/it. FPS shall be entitled to rely on the entry of a username and password into FPS’s systems as confirmation of the identity of the person/entity to whom the username and password were issued. Asset based fees will be assessed on a quarterly billing cycle and will be assessed, pro rata, from the assets in the account. The administration fee will be assessed to the account annually. Participant understands and agrees that these fees may change, from time to time, upon notice from FPS. Participant understands and agrees that certain transaction fees may apply to the account. Participant understands and agrees that these fees may change, from time to time, upon notice from FPS. Participant authorizes and instructs FPS to assess referenced fees (and any other fees Participant may later agree to have assessed against the account) against the account registered in the Participant’s name established under this HSA Enrollment and Agreement Form. SUMMARY OF FEES Administrative Fee: $45 per year. Fee deducted from account balance. (NOTE: If enrolling with an employer group, this fee may be paid in full, or in part, by your employer.) Custodial Fee: 6.25 basis points per quarter (i.e., $0.625 per $1,000 every three months). Fees will be deducted from the account balance quarterly. Transactional Fees Debit Card Fees (if applicable) Withdrawals via paper check $10 Replace lost or stolen debit card $12 Excess contribution correction $25 Additional charge (per card) for three or more debit cards $6 Non-sufficient funds (NSF) $30 Stop payment $25 Transaction correction $25 Copy of debit card merchant receipt $25 Wire transfer (sent or received) $25 Terminate debit card access $25 Duplicate copy of tax document $4 Transfer/rollover to another custodian $25 Account closure $25 INTEREST SCHEDULE There is no minimum account balance required to open a health savings account or to obtain the annual percentage yield disclosed. Interest is credited monthly and based on the balance in your cash/debit card account. The interest rate available on your account is as follows. Balance Interest Rate Balance Interest Rate $25,000 or more 0.50% $5,000.00 – $9,999.99 0.20% $15,000.00 – $24,999.99 0.40% $2,500.00 – $4,999.99 0.10% $10,000.00 – $14,999.99 0.30% $0 - $2,499.99 0.05%