FORM 5305-C UNDER SECTION 223 OF THE INTERNAL REVENUE CODEHsa 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 DISCLOSURESHsa Custodial Agreement • January 4th, 2021
Health Savings Account Custodial Agreement 3 Health Savings Deposit Account Agreement 14 Health Savings Account Truth-In-Savings Disclosure 23 Health Savings Account Funds Availability Disclosure Agreement 25 Health Savings Account External Funds Transfer Agreement 28
HSA CUSTODIAL AGREEMENT AND DISCLOSUREHsa Custodial Agreement • March 6th, 2017
