UMB BANK, N.A. HEALTH SAVINGS ACCOUNT CUSTODIAL AGREEMENT (RETAIN FOR YOUR RECORDS)Health Savings Account Custodial Agreement • September 23rd, 2022 • Missouri
This agreement is made between UMB Bank, n.a. (referred to herein as “we,” “us” or the “Custodian”) and the individual person (referred to herein as “you” or the “Customer”) who completes our HSA enrollment process and satisfies the other requirements we establish in order to open a Health Savings Account (“HSA”) with us. We comply with Section 326 of the USA Patriot Act, which requires us to collect and verify certain information about you when processing your account application. We collect your personal information from you and other sources, such as credit bureaus, affiliates or other companies. You are establishing this Health Savings Account under Section 223(a) of the Internal Revenue Code (the “Code”) exclusively for the purpose of paying or reimbursing your qualified medical expenses or those of your spouse and dependents. You represent that, unless this account is used solely to make rollover contributions, you are eligible to contribute to this HSA; specifically, that: (1) y
HEALTH SAVINGS CUSTODIAL ACCOUNT AGREEMENTHealth Savings Account Custodial Agreement • December 2nd, 2021
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.
FORM 5305-C UNDER SECTION 223 OF THE INTERNAL REVENUE CODEHealth Savings Account Custodial Agreement • April 27th, 2017
The Account Owner named on the Health Savings Account Application (“Account Owner,” and also referred to herein using pronouns such as “you” and “your”) is establishing this Health Savings Account (“HSA” or “Custodial Account” or the “Account”) exclusively for the purpose of paying or reimbursing Qualified Medical Expenses of the Account Owner, his or her spouse, and Dependents. The Account is being opened with Avidia Health, a division of Avidia Bank (the “Bank” or “Custodian,” and also referred to herein using pronouns such as “we,” “us” and “our”). The Account Owner has assigned to this Custodial Account the funds described related to their Health Savings Account. For married persons, each spouse who is eligible to open an HSA and wants to contribute to an HSA must establish his or her own account. The identifying number for an HSA will be the Account Owner’s individual HSA account number.
AVIDIA BANK DISCLOSURESHealth Savings Account Custodial Agreement • January 4th, 2021
The Account Owner named on the Health Savings Account Application (“Account Owner,” and also referred to herein using pronouns such as “you” and “your”) is establishing this Health Savings Account (“HSA” or “Custodial Account” or the “Account”) exclusively for the purpose of paying or reimbursing Qualified Medical Expenses of the Account Owner, his or her spouse, and Dependents. The Account is being opened by Avidia Bank (“Custodian,” and also referred to herein using pronouns such as “we,” “us” and “our”). The Account Owner has assigned to this Custodial Account the funds described related to their Health Savings Account. For married persons, each spouse who is eligible to open an HSA and wants to contribute to an HSA must establish his or her own account. The identifying number for an HSA will be the Account Owner’s individual HSA account number.
U M B B A N K , N . A . H E A L T H S A V I N G S A C C O U N T C U S T O D I A L A G R E E M E N T ( R E T A I N F O R Y O U R R E C O R D S )Health Savings Account Custodial Agreement • September 7th, 2018 • Missouri
This agreement is made between UMB Bank, n.a. (referred to herein as “we,” “us” or the “Custodian”) and the individual person (referred to herein as “you” or the “Customer”) who completes our HSA enrollment process and satisfies the other requirements we establish in order to open a Health Savings Account (“HSA” or “Custodial Account”) with us. By instructing us to open an HSA, depositing funds in or otherwise using the HSA or continuing to hold an HSA with us, you have consented to be bound by this Custodial Agreement, and the UMB Bank, N.A. Health Savings Account Deposit Account Terms and Conditions and all notices, disclosures and other documentation referenced in this Custodial Agreement or relating to the HSA as may be provided to you from time to time.
Health Savings Account Custodial AgreementHealth Savings Account Custodial Agreement • August 8th, 2018 • Connecticut
your Health Savings Account ("HSA"). You and we agree to be bound by the terms of this agreement in connection with administration of your HSA.
HEALTH SAVINGS ACCOUNT CUSTODIAL AGREEMENTHealth Savings Account Custodial Agreement • March 22nd, 2022 • Massachusetts
This Health Savings Account Custodial Agreement contains a Dispute resolution provision that includes an agreement to arbitrate Disputes. The Dispute resolution provision, which is in Section VIII of this Agreement, is called “Dispute Resolution and Binding Arbitration.” Please read this section carefully because it will have a substantial effect on your rights, including your right to bring or participate in a class action or to have a jury trial in the event of a Dispute between you and us. However, even if the section applies to you, you may reject arbitration of Disputes by following the steps noted in that section within 30 days of the Effective Date of this Agreement.
HEALTH SAVINGS ACCOUNT CUSTODIAL AGREEMENTHealth Savings Account Custodial Agreement • January 31st, 2005
The account holder whose name appears on the attached Application ("Depositor") is establishing a Health Savings Account ("HSA") under Section 223(a) of the Internal Revenue Code ("Code") exclusively for the purpose of paying or reimbursing qualified medical expenses of the Depositor and his or her spouse and dependents. The Depositor has assigned to the custodial account the sum indicated on the Application. The Depositor 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 (or as of the effective date as set forth in the Application will be) covered under a high deductible health plan ("HDHP"); is not also covered by any other health plan that is not an HDHP (with certain exceptions for plans providing preventative 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
Health Savings Account (HSA) Custodial Agreement and Disclosure StatementsHealth Savings Account Custodial Agreement • December 3rd, 2020
This Agreement is a contract between you and us regarding each party's rights and responsibilities with regard to your HSA. You are establishing this HSA, as defined in the Internal Revenue Code ("Code") Section 223(d), exclusively for the purpose of paying or reimbursing qualified medical expenses of you, your spouse, and your dependents. In addition to any other representations in this Agreement, you represent that, unless this HSA is used solely to make rollover contributions, you are eligible to contribute to this HSA; specifically, that you (i) are covered under a high deductible health plan ("HDHP"), (ii) are 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) are not enrolled in Medicare, and (iv) cannot be claimed as a dependent on another person's tax return. By establishing an HSA in accordance with the terms of this Agreement, the par
Healthequity Health Savings Account Hsa Custodial AgreementHealth Savings Account Custodial Agreement • June 7th, 2022
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Membership Application Health Savings Account (HSA) Custodial AgreementHealth Savings Account Custodial Agreement • October 28th, 2020
The account owner named below 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.
VOYA HEALTH SAVINGS ACCOUNT CUSTODIAL AGREEMENTHealth Savings Account Custodial Agreement • November 17th, 2022 • Connecticut
The Account Owner is establishing a Health Savings Account (an “HSA” and, with respect to the Account Owner, the “Account”), as defined in Internal Revenue Code (“Code”) Section 223, with Voya Institutional Trust Company 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 the Account is used solely to make rollover contributions, the Account Owner is eligible to contribute to the Account; specifically, that the Account Owner: (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 Custodial AgreementHealth Savings Account Custodial Agreement • October 17th, 2005
Thank you for choosing Aetna Life Insurance Company (“us” or “we”) as the custodian of your Health Savings Account (“HSA”). You and we agree to be bound by the terms of this agreement in connection with administration of your HSA.
HEALTH SAVINGS ACCOUNT CUSTODIAL AGREEMENTHealth Savings Account Custodial Agreement • October 11th, 2017 • Connecticut
This Custodial Agreement applies to all persons establishing a- Health Savings Account (HSA) under Section 223(a) of the Internal Revenue Code (“Code”) exclusively for the purpose of paying or reimbursing qualified medical expenses of the person and his or her spouse and dependents. This Health Savings Account Custodial Agreement does not apply to any other type of Account.
HEALTH SAVINGS ACCOUNT CUSTODIAL AGREEMENTHealth Savings Account Custodial Agreement • July 6th, 2004
The depositor whose name appears on the attached Application is establishing a Health Savings Account under Section 223(a) of the Internal Revenue Code (“Code”) for the
Health Savings Account Custodial AgreementHealth Savings Account Custodial Agreement • June 25th, 2021
Health Savings Account Custodial Agreement (Under Section 223(a) of the Internal Revenue Code)Health Savings Account Custodial Agreement • July 11th, 2024 • Illinois
HEALTH SAVINGS ACCOUNT CUSTODIAL AGREEMENTHealth Savings Account Custodial Agreement • March 21st, 2005
The accountholder whose name appears on the attached Application ("Depositor") is establishing a Health Savings Account ("HSA") under Section 223(a) of the Internal Revenue Code ("Code") exclusively for the purpose of paying or reimbursing qualified medical expenses of the Depositor and his or her spouse and dependents. The Depositor has assigned to the custodial account the sum indicated on the Application. The Depositor 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 (or as of the effective date as set forth in the Application will be) 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 preventative 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 anoth
Health Savings Account Custodial AgreementHealth Savings Account Custodial Agreement • December 13th, 2023
This Health Savings Account Custodial Agreement (“Agreement”) sets forth the terms and conditions that govern your Health Savings Account (“Account” or “HSA”) with DataPath Financial Services. Throughout this Agreement, the words “Custodian,” “DFS,” “we,” “us,” or “our” means DataPath Financial Services, Inc., its successors and assigns and “you,” “your,” or “yours” means the named account owner of the HSA, any spouse beneficiary upon the death of the HSA owner, or any third- party authorized or appointed to access and use the HSA. The terms of this Agreement shall be binding upon you and the Custodian.
Fifth Third Bank Health Savings Account Custodial AgreementHealth Savings Account Custodial Agreement • April 14th, 2017 • Ohio
The Account Owner named on the Application is establishing this Fifth Third Bank 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 Custodian is Fifth Third Bank. In this Agreement, the words “you” and “your” shall refer to the Account Owner. The words “we”, “us” and “our” shall refer to the Custodian. You represent that, unless this account is used solely to make rollover contributions, you are eligible to contribute to this HSA in that you: (1) are covered under a high deductible health plan (HDHP);
Health Savings Account Custodial AgreementHealth Savings Account Custodial Agreement • May 21st, 2021
All HSA Consumers are required to accept the HSA Custodial Agreement. EMPOWER offers this form to Consumers who are unable to accept the agreement electronically. If you are unable to sign the Agreement online, follow the below instructions.
HEALTH SAVINGS CUSTODIAL ACCOUNT AGREEMENTHealth Savings Account Custodial Agreement • September 26th, 2014 • Colorado
The Account Owner named on the HSA 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 tax 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 (or will be as of the effective date of this Agreement) 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 CUSTODIAL AGREEMENTHealth Savings Account Custodial Agreement • December 19th, 2003
The depositor whose name appears on the attached Application is establishing a Health Savings Account under Section 223(a) of the Internal Revenue Code (“Code”) for the purpose of paying qualified medical expenses, as defined under Section 223(d)(2) of the Code, of the Depositor. The Depositor has assigned the custodial account the sum indicated on the Application.
