Health Savings Account (HSA) Custodial AgreementHsa Custodial Agreement • March 30th, 2021
This document describes your responsibilities as well. You must agree to follow the rules described below and to pay for our services. We may refer to you as the “Accountholder,” but more often, we will use the terms “you” or “your.”
HSA CUSTODIAL AGREEMENT AND DISCLOSUREHsa Custodial Agreement • March 6th, 2017
Everence HSA Custodial AgreementHsa Custodial Agreement • October 7th, 2014
The account owner whose name appears on the Everence HSA application is establishing this HSA under Internal Revenue Code section 223 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 or direct transfer contributions, he or she is eligible to contribute to this HSA. The account owner and Everence Federal Credit Union as the custodian make the following agreement:
HSA Custodial Agreement and Disclosure StatementHsa Custodial Agreement • 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.
