Common Contracts
2 similar Custodial Agreement and Disclosure Statement contracts
Custodial Agreement and Disclosure StatementCustodial Agreement and Disclosure Statement • August 17th, 2015
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 (i) is covered under a high deductible health plan (“HDHP”), (ii) 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), (iii) is not enrolled in Medicare, and (iv) cannot be claimed as a dependent on another person’s tax return. Healthcare Bank, a division of Bell State Bank & Trust is the “Custodian” under this agreement and the Third Party Administrator (“TPA”) is the “Designated Representative” and “HSA Administrator.”
Custodial Agreement and Disclosure StatementCustodial Agreement and Disclosure Statement • November 17th, 2009
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 (i) is covered under a high deductible health plan (HDHP), (ii) 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), (iii) is not enrolled in Medicare, and (iv) cannot be claimed as a dependent on another person’s tax return. Healthcare Bank is the “Custodian” under this agreement and TPA is the “Designated Representative.”
