THIS DOCUMENT MAY ONLY BE USED WITH A SOUTWEST SECURITIES ACCOUNT.Health Savings Account Agreement • May 18th, 2012
• Complete and sign the Health Savings Account Application.1 All beneficiary information including Social Security numbers should be completed.
HEALTH SAVINGS TRUST ACCOUNT AGREEMENTHealth Savings Account Agreement • August 7th, 2013
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 ACCOUNT AGREEMENT & DISCLOSURE STATEMENTHealth Savings Account Agreement • August 25th, 2022
This Health Savings Account Agreement and Disclosure Statement (this “Agreement”) is entered into by and between the account owner (referred to in this Agreement as “you” and “your”) and The Bank of New York Mellon (referred to in this Agreement as “we”, “us”, and “our”). It specifies the terms of the Health Savings Account you are opening with us (your “Account”). Your Account is as an individual custodial account established in accordance with the statutory requirements of Section 223 of the Internal Revenue Code (the “Code”) governing health savings accounts (“HSA”), and we will serve as the custodian for your Account pursuant to this Agreement. Contributions and distributions from your account are subject to applicable Internal Revenue Service regulations and your account agreement with us.
TRUTH-IN-SAVINGS ACCOUNT DISCLOSURE DEPOSIT ACCOUNT AGREEMENTHealth Savings Account Agreement • March 25th, 2021 • Indiana
This schedule sets forth certain conditions, rates, fees and charges that are specific to your Health Savings Account (“Account”). Subject to applicable law and the terms of the Deposit Account Agreement, we may amend the rates, fees and charges contained in this schedule from time to time.
VOLUNTARY FORMHealth Savings Account Agreement • October 3rd, 2018
This form is voluntary. If you would like to contribute additional money into this account, a tax deductible contribution will be taken out of your pay check in each of the 20 pay cycles determined at the beginning of the school year.
Account AgreementHealth Savings Account Agreement • March 24th, 2020 • Indiana
This Account Agreement (“Agreement”) provides information regarding your account with Elements Financial Federal Credit Union (“Credit Union”). This Agreement is in addition to any and all other membership, loan, or service agreements and disclosures you may receive in connection with obtaining additional accounts, loans or services with the Credit Union.
THIS DOCUMENT MAY ONLY BE USED WITH A SOUTWEST SECURITIES ACOUNT.Health Savings Account Agreement • November 29th, 2007
• Complete and sign the Health Savings Account Application.1 All beneficiary information including Social Security numbers should be completed.
HSA AgreementHealth Savings Account Agreement • September 10th, 2010
• On this form, you authorize the amount(s) to be contributed from your salary to a Health Savings on your behalf. Please print the information in black ink.
Health Savings Account Agreement FormHealth Savings Account Agreement • October 4th, 2019
Employer Name La Plata County Name (Last, First, MI) Employee Number Street Address City State ZIP Code Effective Date of Election Type of Election Date of Birth-MM/DD/YY New Election New Hire ElectionChange in Election Stop Election Health Savings Account Election HSA Custodian – Central Bank Per Pay Period Salary Reduction AmountCheck the medical plan coverage tier that you have enrolled in.Employee Only HDHP Coverage Family HDHP Coverage Indicate the Per Pay Period Amount that you wish to contribute to the HSA$
AGREEMENT AND DISCLOSUREHealth Savings Account Agreement • September 26th, 2014 • Colorado
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.
Account AgreementHealth Savings Account Agreement • March 24th, 2020 • Indiana
This Account Agreement (“Agreement”) provides information regarding your account with Elements Financial Federal Credit Union (“Credit Union”). This Agreement is in addition to any and all other membership, loan, or service agreements and disclosures you may receive in connection with obtaining additional accounts, loans or services with the Credit Union.
ContractHealth Savings Account Agreement • September 25th, 2020
As set forth under this Agreement, the HSA Owner may make contributions to the HSA. Based on the value of the HSA and minimum amounts defined under this agreement, funds may be moved between the Cash Portion and Investment Portion of the Account. These funds may either be in a deposit account at a financial institution selected by Custodian or an investment account at an outside investment company, at the HSA Owner’s direction.
HEALTH SAVINGS ACCOUNT AGREEMENTHealth Savings Account Agreement • February 19th, 2024
HEALTH SAVINGS ACCOUNT SD AGREEMENT ADDENDUMHealth Savings Account Agreement • June 11th, 2016
Account Agreement/Signature CardHealth Savings Account Agreement • April 10th, 2023
IMPORTANT: Please return a copy of two forms of identification for yourself and the Authorized Signer (If Applicable). This must be one unexpired photo id such as Driver’s License or other Government Issued Document and a second form which may include but is not limited to a social security card, birth certificate, work id, library card, hunting license or other form of government issued id.
HEALTH SAVINGS ACCOUNT SD AGREEMENT ADDENDUMHealth Savings Account Agreement • July 8th, 2019
