Establishment of the Custodial Account. Purpose of your Account and your eligibility. As the Account owner, you establish this HSA for the exclusive purpose of paying or reimbursing your qualified medical expenses and those of your spouse and your dependents. You represent that, unless you use this Account solely to make rollover contributions, you are eligible to contribute to this HSA. You further represent that: (1) you have healthcare coverage under a high deductible health plan (HDHP); (2) you have no 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) you are not enrolled in Medicare; and (4) no other person can claim you as a dependent on their tax return.
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Samples: Electronic Access Agreement, www.mybenefitwallet.com, www.mybenefitwallet.com