Common Contracts
12 similar Custodial Agreement and Disclosure Statement contracts
Custodial Agreement and Disclosure StatementCustodial Agreement and Disclosure Statement • September 18th, 2020
The Accountholder is establishing this Health Savings Account (“HSA”) exclusively for the purpose of paying or reimbursing qualified medical expenses of the Accountholder, his or her spouse, and dependents. The Accountholder 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. Healthcare Bank, a division of Bell Bank is the “Custodian” under this agreement.
Custodial Agreement and Disclosure StatementCustodial Agreement and Disclosure Statement • September 18th, 2020
The Accountholder is establishing this Health Savings Account (“HSA”) exclusively for the purpose of paying or reimbursing qualified medical expenses of the Accountholder, his or her spouse, and dependents. The Accountholder 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. Healthcare Bank, a division of Bell Bank is the “Custodian” under this agreement.
Custodial Agreement and Disclosure StatementCustodial Agreement and Disclosure Statement • September 18th, 2020
The Accountholder is establishing this Health Savings Account (“HSA”) exclusively for the purpose of paying or reimbursing qualified medical expenses of the Accountholder, his or her spouse, and dependents. The Accountholder 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. Healthcare Bank, a division of Bell Bank is the “Custodian” under this agreement.
Custodial Agreement and Disclosure StatementCustodial Agreement and Disclosure Statement • May 5th, 2020
The Accountholder is establishing this Health Savings Account (“HSA”) exclusively for the purpose of paying or reimbursing qualified medical expenses of the Accountholder, his or her spouse, and dependents. The Accountholder 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. Healthcare Bank, a division of Bell Bank is the “Custodian” under this agreement.
Custodial Agreement and Disclosure StatementCustodial Agreement and Disclosure Statement • October 24th, 2019
The Accountholder is establishing this Health Savings Account (“HSA”) exclusively for the purpose of paying or reimbursing qualified medical expenses of the Accountholder, his or her spouse, and dependents. The Accountholder 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. Healthcare Bank, a division of Bell Bank is the “Custodian” under this agreement.
Custodial Agreement and Disclosure StatementCustodial Agreement and Disclosure Statement • November 12th, 2018
The Accountholder is establishing this Health Savings Account (“HSA”) exclusively for the purpose of paying or reimbursing qualified medical expenses of the Accountholder, his or her spouse, and dependents. The Accountholder 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. Healthcare Bank, a division of Bell Bank is the “Custodian” under this agreement.
Custodial Agreement and Disclosure StatementCustodial Agreement and Disclosure Statement • September 10th, 2018
The Accountholder is establishing this Health Savings Account (“HSA”) exclusively for the purpose of paying or reimbursing qualified medical expenses of the Accountholder, his or her spouse, and dependents. The Accountholder 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. Healthcare Bank, a division of Bell Bank is the “Custodian” under this agreement.
Custodial Agreement and Disclosure StatementCustodial Agreement and Disclosure Statement • September 10th, 2018
The Accountholder is establishing this Health Savings Account (“HSA”) exclusively for the purpose of paying or reimbursing qualified medical expenses of the Accountholder, his or her spouse, and dependents. The Accountholder 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. Healthcare Bank, a division of Bell Bank is the “Custodian” under this agreement.
Custodial Agreement and Disclosure StatementCustodial Agreement and Disclosure Statement • September 21st, 2017
The Accountholder is establishing this Health Savings Account (“HSA”) exclusively for the purpose of paying or reimbursing qualified medical expenses of the Accountholder, his or her spouse, and dependents. The Accountholder 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. Healthcare Bank, a division of Bell Bank is the “Custodian” under this agreement.
Custodial Agreement and Disclosure StatementCustodial Agreement and Disclosure Statement • September 19th, 2017
The Accountholder is establishing this Health Savings Account (“HSA”) exclusively for the purpose of paying or reimbursing qualified medical expenses of the Accountholder, his or her spouse, and dependents. The Accountholder 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. Healthcare Bank, a division of Bell Bank is the “Custodian” under this agreement.
Custodial Agreement and Disclosure StatementCustodial Agreement and Disclosure Statement • September 15th, 2017
The Accountholder is establishing this Health Savings Account (“HSA”) exclusively for the purpose of paying or reimbursing qualified medical expenses of the Accountholder, his or her spouse, and dependents. The Accountholder 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. Healthcare Bank, a division of Bell Bank is the “Custodian” under this agreement.
Custodial Agreement and Disclosure StatementCustodial Agreement and Disclosure Statement • August 24th, 2016
Notification of Amendment: When you executed the Custodial Agreement and Disclosure Statement online, you agreed to electronic delivery of all notices and documents related to your account. Article XI of the Custodial Agreement and Disclosure Statement has been modified to simplify the language and make it easier to read and understand, but without making substantive changes except as follows: (1) sections 11.05 and 11.24 have been amended to permit the HSA Administrator to close your HSA if the balance is zero and you have terminated employment (because your former employer no longer pays the administration fee and it cannot be withdrawn from the HSA); (2) the phrase “third party administrator” or “TPA” has been changed to the “HSA Administrator” throughout (this is simply a language change); and (3) the role of your HSA Administrator has been clarified to provide that it serves as a vendor of the Bank, but not as your designated representative, though your HSA Administrator will perf
