... HSA ... Health Savings Account. Custodial. (includes self-direction)

Transcription

1 HSA Heath Savings Account Custodia (incudes sef-direction)

2 ADDITIONAL INFORMATION Purpose This Organizer contains documents necessary to estabish a Heath Savings Account (HSA) It meets the requirements of Interna Revenue Code (IRC) Section 223, other reevant IRC sections, and a additiona Interna Revenue Service (IRS) guidance An HSA is estabished after the Organizer is fuy executed by both you (account owner) and the custodian and must be competed no ater than the due date (excuding extensions) of your income tax return for the tax year Do not fie the HSA Custodia Account Agreement with the IRS Instead, keep it with your records How to use this HSA Organizer You must compete and sign the Appication An origina signed copy of the Appication shoud be kept by the custodian for its records You shoud receive a copy of the Appication and keep the remaining contents of the HSA Organizer Community or marita property state aws may require spousa consent for nonspouse beneficiary designations Definitions HSA An HSA is a tax-exempt trust or custodia account estabished excusivey for the purpose of paying quaified medica expenses of you, your spouse, and your dependents Custodian An HSA custodian must be a bank, an insurance company, a person previousy approved by the IRS to be a custodian of an individua retirement account (IRA) or Archer Medica Savings Account (MSA), or any other person approved by the IRS Account Owner The account owner is the person who estabishes the custodia account For HSA purposes, the account owner is you Additiona Documents Appicabe aw or poicies of the HSA custodian may require additiona documentation such as IRS Form W-9, Request for Taxpayer Identification Number and Certification For Additiona Guidance It is in your best interest to seek the guidance of a tax or ega professiona before competing this document For more information, refer to IRC Section 223, other reevant IRC sections, and a additiona IRS guidance; IRS pubications that incude information about HSAs; instructions to your federa income tax return; your oca IRS office; or the IRS's web site at wwwirsgov Woters Kuwer Financia Services - Bankers Systems* Form HSA-CUSORGLZ Rev 2/1/2007 (page 1 of 8)

3 Heath Savings Account (HSA) Appication HSA OWNER INFORMATION NAME, ADDRESS, CITY, STATE, AND ZIP (Custodian's name, address, and phone number above) HSA ACCOUNT (PLAN) NUMBER SOCIAL SECURITY NUMBER (SSN) PERCENTAGE PERCENTAGE DAYTIME PHONE NUMBER CONTRIBUTION INFORMATION (OPTIONAL) Type of Heath Insurance Pan Coverage (seect one): Sef-Ony Famiy DATE OF BIRTH INVESTMENT NUMBER AMOUNT CONTRIBUTION DATE TAX YEAR CONTRIBUTION TYPE (seect one): Reguar Roover from an HSA Transfer from an HSA Contribution from an IRA Return of Mistaken Distribution DESIGNATION OF BENEFICIARY SPOUSAL CONSENT SIGNATURES $ NAME OF BENEFICIARY NAME OF BENEFICIARY SSN OR TAXPAYER IDENTIFICATION NUMBER SSN OR TAXPAYER IDENTIFICATION NUMBER GENDER: At the time of my death, the primary beneficiaries named beow wi receive my HSA assets If a of my primary beneficiaries die before me, the contingent beneficiaries named beow wi receive my HSA assets In the event a beneficiary dies before me, such beneficiary's share wi be reaocated on a pro-rata basis to the other beneficiaries that share the deceased beneficiary's cassification as a primary or contingent beneficiary If a of the beneficiaries die before me, my HSA assets wi be paid to my estate If no percentages are assigned to beneficiaries, the beneficiaries wi share equay If the percentage tota for each beneficiary cassification does not equa 100 percent, any remaining percentage wi be divided equay among the beneficiaries within such cass This designation revokes and supercedes a earier beneficiary designations which may appy to this HSA A Primary Beneficiary Tota 100 B Contingent Beneficiary Tota 100 RELATIONSHIP TO HSA OWNER RELATIONSHIP TO HSA OWNER Community or marita property state aws may require spousa consent for a nonspouse beneficiary designation The aws of the state in which the financia organization is domicied, the HSA owner resides, the trust is ocated, the spouse resides, or this transaction is consummated shoud be reviewed to determine if such a requirement exists Spousa consent for the beneficiary designation may aso be required by financia organization poicy I Am Married I understand that if I designate a primary beneficiary other than my spouse, my spouse must consent by signing (HSA Owner Initias) beow I Am Not Married I understand that if I marry in the future, I must compete a new Designation of Beneficiary form, which incudes the spousa consent documentation (HSA Owner Initias) I am the spouse of the HSA owner Because of the significant consequences associated with giving up my interest in the HSA, the custodian has not provided me with ega or tax advice, but has advised me to seek tax or ega advice I acknowedge that I have received a fair and reasonabe discosure of the HSA owner's assets or property, incuding any financia obigations for a community property state In the event I have a ega interest in the HSA assets, I hereby give to the HSA owner such interest in the assets hed in this HSA and consent to the beneficiary designation set forth in Section 3 of this form Signature of Spouse Date Catch-Up (age 55 or oder and not enroed in Medicare) Roover from an Archer Medica Savings Account Transfer from an Archer Medica Savings Account Roover from a Heath Reimbursement Arrangement/ Heath Fexibe Spending Account Signature of Witness (if required) (Witness cannot be a beneficiary of this HSA) If this HSA is being estabished with a reguar contribution, I certify that I am covered by a quaified high deductibe heath pan (HDHP), and that I am not covered by a heath pan other than an HDHP that provides any of the same benefits as an HDHP I certify that the information provided by me on this Appication is accurate, and that I have received a copy of the Appication, IRS Form 5305-C, Heath Savings Custodia Account, and Discosure Statement I agree to be bound by the terms and conditions found in the Appication, Heath Savings Custodia Account, Discosure Statement, and amendments thereto I assume soe responsibiity for a consequences reating to my actions concerning this HSA I have not received any tax or ega advice from the custodian, and I wi seek the advice of my own tax or ega professiona to ensure my compiance with reated aws I reease and agree to hod the HSA custodian harmess against any and a caims or osses arising from my actions Mae Date Femae Signature of HSA Owner Date Signature of Custodian Date Woters Kuwer Financia Services - Bankers Systems* Form HSA-CUSORGLZ Rev 2/1/2007 (page 2 of 8)

4 HEALTH 5305-C SAVINGS CUSTODIAL ACCOUNT (Under section 223(a) of the Interna Revenue Code) Form (August 2004) Department of the Treasury Interna Revenue Service The account owner and the custodian make the foowing agreement: Artice I 1 The custodian wi accept additiona cash contributions for the tax year made by the account owner or on behaf of the account owner (by an empoyer, famiy member or any other person) No contributions wi be accepted by the custodian for any account owner that exceeds the maximum amount for famiy coverage pus the catch-up contribution 2 Contributions for any tax year may be made at any time before the deadine for fiing the account owner's federa income tax return for that year (without extensions) 3 Roover contributions from an HSA or an Archer Medica Savings Account (Archer MSA) (uness prohibited under this agreement) need not be in cash and are not subject to the maximum annua contribution imit set forth in Artice II Artice II 1 For caendar year 2004, the maximum annua contribution imit for an account owner with singe coverage is the esser of the amount of the deductibe under the HDHP but not more than $2,600 For caendar year 2004, the maximum annua contribution imit for an account owner with famiy coverage is the esser of the amount of the deductibe under the HDHP but not more than $5,150 These imits are subject to cost-of-iving adjustments after 2004 Eigibiity and contribution imits are determined on a month-to-month basis 2 Contributions to Archer MSAs or other HSAs count toward the maximum annua contribution imit to this HSA 3 For caendar year 2004, an additiona $500 catch-up contribution may be made for an account owner who is at east age 55 or oder and not enroed in Medicare The catch-up contribution increases to $600 in 2005, $700 in 2006, $800 in 2007, $900 in 2008, and $1,000 in 2009 and ater years 4 Contributions in excess of the maximum annua contribution imit are subject to an excise tax However, the catch-up contributions are not subject to an excise tax Artice III It is the responsibiity of the account owner to determine whether contributions to this HSA have exceeded the maximum annua contribution imit described in Artice II If contributions to this HSA exceed the maximum annua contribution imit, the account owner sha notify the custodian that there exist excess contributions to the HSA It is the responsibiity of the account owner to request the withdrawa of the excess contribution and any net income attributabe to such excess contribution Artice IV The account owner's interest in the baance in this custodia account is nonforfeitabe Artice V 1 No part of the custodia funds in this account may be invested in ife insurance contracts or in coectibes as defined in section 408(m) 2 The assets of this account may not be comminged with other property except in a common trust fund or common investment fund 3 Neither the account owner nor the custodian wi engage in any prohibited transaction with respect to this account (such as borrowing or pedging the account or engaging in any other prohibited transaction as defined in section 4975) Artice VI 1 Distributions of funds from this HSA may be made upon the direction of the account owner 2 Distributions from this HSA that are used excusivey to pay or reimburse quaified medica expenses of the account owner, his or her spouse, or dependents are tax-free However, distributions that are not used for quaified medica expenses are incuded in the Do not Fie with Interna Revenue Service Amendment account owner's gross income and are subject to an additiona 10 percent tax on that amount The additiona 10 percent tax does not appy if the distribution is made after the account owner's death, disabiity, or reaching age 65 3 The custodian is not required to determine whether the distribution is for the payment or reimbursement of quaified medica expenses Ony the account owner is responsibe for substantiating that the distribution is for quaified medica expenses and must maintain records sufficient to show, if required, that the distribution is tax-free Artice VII If the account owner dies before the entire interest in the account is distributed, the entire account wi be disposed of as foows: 1 If the beneficiary is the account owner's spouse, the HSA wi become the spouse's HSA as of the date of death 2 If the beneficiary is not the account owner's spouse, the HSA wi cease to be an HSA as of the date of death If the beneficiary is the account owner's estate, the fair market vaue of the account as of the date of death is taxabe on the account owner's fina return For other beneficiaries, the fair market vaue of the account is taxabe to that person in the tax year that incudes such date Artice VIII 1 The account owner agrees to provide the custodian with information necessary for the custodian to prepare any report or return required by the IRS 2 The custodian agrees to prepare and submit any report or return as prescribed by the IRS Artice IX Notwithstanding any other artice that may be added or incorporated in this agreement, the provisions of Artices I through VIII and this sentence are controing Any additiona artice in this agreement that is inconsistent with section 223 or IRS pubished guidance wi be void Artice X This agreement wi be amended from time to time to compy with the provisions of the Code or IRS pubished guidance Other amendments may be made with the consent of the persons whose signatures appear on the Appication that accompanies this Agreement Artice XI 1101 Your HSA Documents This Agreement for an HSA, and any amendments or additiona provisions to such agreement, set forth the terms and conditions governing the account owner's HSA reationship with us This Agreement wi be accompanied by a discosure statement, which sets forth various HSA rues in simper anguage 1102 Definitions This Agreement refers to you as the account owner, and us as the custodian References to "you," "your," and "HSA owner" wi mean the account owner, and "we," "us," and "our" wi mean the custodian Upon your death, your spouse beneficiary, if appicabe, becomes "you" for purposes of this Agreement In the event you appoint a third party, or have a third party appointed on your behaf to hande certain transactions affecting your HSA, such third party wi be considered your agent and, therefore, "you" for purposes of this Agreement Additionay, references to "HSA" wi mean the custodia account 1103 Additiona Provisions Additiona provisions may be attached to, and made a part of, this Agreement by either party The provisions must be in writing, agreed to by us, and in a format acceptabe to us 1104 Our Fees and Expenses We may charge reasonabe fees and are entited to reimbursement for any expenses we incur 2004 Woters Kuwer Financia Services - Bankers Systems Form HSA-CUSORGLZ Rev 2/1/2007 * - (page 3 of 8)

5 in estabishing and maintaining your HSA We may change a resut of events beyond our contro We have no the fees at any time by providing you with notice of such changes We wi provide you with fee discosures and responsibiity to process transactions unti after we have received appropriate direction and documentation, and we poicies Fees may be deducted directy from your HSA have had a reasonabe opportunity to process the assets, and/or bied separatey to you Fees bied separatey transactions We are not responsibe for interpreting or to you and paid by you may be caimed on your federa directing beneficiary designations or divisions, incuding income tax return as misceaneous itemized deductions The separate accounting, court orders, penaty exception payment of fees has no effect on your contributions determinations, or other simiar situations Additionay, we have the right to iquidate your HSA assets 1111 Investment of HSA Assets to pay such fees and expenses If you do not direct us on the (a) Investment of Contributions We wi invest HSA iquidation, we wi iquidate the assets of our choice and wi not be responsibe for any osses or caims that may arise out of the iquidation 1105 Amendments We may amend your HSA in any respect and contributions and reinvest your HSA assets as directed by you based on our then-current investment poicies and procedures If you fai to provide us with investment direction for a contribution, we wi return or hod a or at any time, incuding retroactivey, to compy with part of such contribution based on our poicies and appicabe aws governing HSAs and the corresponding procedures We wi not be responsibe for any oss of reguations Any other amendments sha require your HSA income associated with your faiure to provide consent, by action or no action, and wi be preceded by appropriate investment direction written notice to you Uness otherwise required, you are (b) Directing Investments A investment directions must deemed to automaticay consent to an amendment, which means that your written approva is not required for the amendment to appy to the HSA In certain instances the governing aw or our poicies may require us to secure your written consent before an amendment can be appied to the be in a format or manner acceptabe to us You may invest in any HSA investments that you are quaified to purchase, and that we are authorized to offer and do offer at the time of the investment seection, and that are acceptabe under the appicabe aws governing HSAs HSA If you want to withhod your consent to an Your HSA investments wi generay be registered in amendment, you must provide us with a written objection within 30 days of the receipt date of the amendment our name or our nominee's name (if appicabe) for the benefit of your HSA Specific investment information 1106 Notice and Deivery Any notice maied to you wi be may be provided at the time of the investment deemed deivered and received by you, five days after the postmark date This fifth day foowing the postmark is the Based on our poicies, we may aow you to deegate the investment responsibiity of your HSA to an agent by receipt date Notices wi be maied to the ast address we providing us with written notice of deegation in a have in our records You are responsibe for ensuring that we have your proper maiing address Upon your consent, we may provide you with notice in a deivery format other than by mai Such formats may incude various eectronic deiveries Any notice, incuding terminations, change in persona information, or contributions maied to us wi be format acceptabe to us We wi not review or guide your agent's decisions, and you are responsibe for the agent's actions or faiure to act We are not responsibe for directing your investments, or providing investment advice, incuding guidance on the suitabiity or potentia market vaue of various investments For investments in deemed deivered when actuay received by us based on our securities, we wi exercise voting rights and other ordinary business practices A notices must be in writing uness our poicies and procedures provide for ora notices simiar rights ony at your direction, and according to our then-current poicies and procedures 1107 Appicabe Laws This Agreement wi be construed and (c) Investment Fees and Asset Liquidation Certain interpreted in accordance with the aws of, and venued in, our state of domicie 1108 Disquaifying Provisions Any provision of this Agreement that woud disquaify the HSA wi be disregarded to the extent necessary to maintain the account as an HSA investment-reated fees, which appy to your HSA, must be charged to your HSA and cannot be paid by you We have the right to iquidate your HSA assets to pay fees and expenses, federa tax evies, or other assessments on your HSA If you do not direct us on the iquidation, we 1109 Interpretation If any question arises as to the meaning of wi iquidate the assets of our choice and wi not be any provision of this Agreement, then we sha be responsibe for any osses or caims that may arise out of authorized to interpret any such provision, and our the iquidation interpretation wi be binding upon a parties (d) Deposit Investments The deposit investments provided 1110 Representations and Indemnity You represent that any by us may incude savings, share, and/or money market information you and/or your agents provide to us is accurate accounts, and various certificates of deposit (CDs) and compete, and that your actions compy with this (e) Non-Deposit Investments Non-deposit investments Agreement and appicabe aws governing HSAs You incude investments in property, annuities, mutua funds, understand that we wi rey on the information provided by stocks, bonds, and government, municipa and US you, and that we have no duty to inquire about or Treasury securities, and other simiar investments Most, investigate such information We are not responsibe for any osses or expenses that may resut from your information, direction, or actions, incuding your faiure to act You agree to hod us harmess, to indemnify, and to defend us if not a, of the investments we offer are subject to investment risks, incuding possibe oss of the principa amount invested Specific investment discosures may be provided to you against any and a actions or caims arising from, and 1112 Distributions Withdrawa requests must be in a format iabiities and osses incurred by reason of your information, direction, or actions Additionay, you represent that it is your responsibiity to seek the guidance of a tax or ega professiona for your HSA issues acceptabe to us, and/or on forms provided by us We may require you, or your beneficiary after your death, to provide documentation and a proper tax identification number before we process a distribution These withdrawas may be subject We are not responsibe for determining whether any to taxes, withhoding, and penaties Distributions wi contributions or distributions compy with this Agreement generay be in cash or in kind based on our poicies and/or the federa aws governing HSAs We are not In-kind distributions wi be vaued according to our poicies responsibe for any taxes, judgments, penaties or expenses incurred in connection with your HSA, or any osses that are at the time of the distribution Any distribution by check, debit card or other method approved by us wi be reported Woters Kuwer Financia Services - Bankers Systems* Form HSA-CUSORGLZ Rev 2/1/2007 (page 4 of 8)

6 as a norma distribution, uness we inform you otherwise or uness - at the time of the distribution - we provide you with a means to state otherwise and you in fact state otherwise Our poicies may permit us to accept the return of a mistaken distribution 1113 Transfer and Roover Contributions We may accept transfers, roovers, and other simiar contributions, remotey or in person, in cash or in kind from other HSAs and from Archer Medica Savings Accounts (MSAs) Prior to competing such transactions we may require that you provide certain information in a format acceptabe to us In-kind contributions wi be vaued according to our poicies and procedures at the time of the contribution 1114 Reports and Records We wi maintain the records necessary for IRS reporting on this HSA Required reports wi be provided to you, or your beneficiary after your death, and the IRS If you beieve that your report is inaccurate or incompete you must notify us in writing within 30 days foowing the receipt date Your investments may require additiona state and federa reporting 1115 Termination You may terminate this Agreement without our consent by providing us with a written notice of termination A termination and the resuting distribution or transfer wi be processed and competed as soon as administrativey feasibe foowing the receipt of proper notice At the time of termination we may retain the sum necessary to cover any fees and expenses, taxes, or investment penaties 1116 Our Resignation Ẇe can resign at any time by providing you with 30 days written notice prior to the resignation date, or within five days of our receipt of your written objection to an amendment In the event you materiay breach this Agreement, we can terminate this Agreement by providing you with five days prior written notice Upon our resignation, you must appoint a quaified successor custodian or trustee Your HSA assets wi be transferred to the successor custodian or trustee once we have received appropriate direction Transfers wi be competed within a reasonabe time foowing our resignation notice and the payment of your remaining HSA fees or expenses We reserve the right to retain HSA assets to pay any remaining fees or expenses At the time of termination we may retain the sum necessary to cover any fees and expenses, taxes, or investment penaties If you fai to provide us with acceptabe transfer direction within 30 days from the date of the notice, we can transfer the assets to a successor custodian or trustee of our choice, distribute the assets to you in kind, or iquidate the assets and distribute them to you in cash 1117 Successor Organization If we merge with, purchase, or are acquired by, another organization, such organization, if quaified, may automaticay become the successor custodian or trustee of your HSA 1118 Tax Year of Contributions Any transaction, incuding a remote transaction - such as a computer/internet, ATM, or night deposit transaction - that resuts in a reguar contribution to the HSA is considered a current tax year contribution However, we may aow you to specify the tax year for a reguar contribution at the time of the contribution IRS FORM 5305-C INSTRUCTIONS (8-2004) Genera Instructions Section references are to the Interna Revenue Code Purpose of Form Form 5305-C is a mode custodia account agreement that has been approved by the IRS An HSA is estabished after the form is fuy executed by both the account owner and the custodian The form can be competed at any time during the tax year This account must be created in the United States for the excusive benefit of the account owner Do not fie Form 5305-C with the IRS Instead, keep it with your records For more information on HSAs, see Notice , IRB 269, Notice , IRB 196, Pubication 969, and other IRS pubished guidance Definitions Identifying Number The account owner's socia security number wi serve as the identification number of this HSA For married persons, each spouse who is eigibe to open an HSA and wants to contribute to an HSA must estabish his or her own account An empoyer identification number (EIN) is required for an HSA for which a return is fied to report unreated business taxabe income An EIN is aso required for a common fund created for HSAs Form 5305-C (8-2004) High Deductibe Heath Pan (HDHP) For caendar year 2004, an HDHP for sef-ony coverage has a minimum annua deductibe of $1,000 and an annua out-of-pocket maximum (deductibes, co-payments and other amounts, but not premiums) of $5,000 For caendar year 2004, an HDHP for famiy coverage has a minimum annua deductibe of $2,000 and an annua out-of-pocket maximum of $10,000 These imits are subject to cost-of-iving adjustments after 2004 Sef-ony coverage and famiy coverage under an HDHP Famiy coverage means coverage that is not sef-ony coverage Quaified medica expenses Quaified medica expenses are amounts paid for medica care as defined in section 213(d) for the account owner, his or her spouse, or dependents (as defined in section 152) but ony to the extent that such amounts are not compensated for by insurance or otherwise With certain exceptions, heath insurance premiums are not quaified medica expenses See Notice , IRB 727 for transition reief for distributions for quaified medica expenses incurred in caendar year 2004 Custodian A custodian of an HSA must be a bank, an insurance company, a person previousy approved by the IRS to be a custodian of an individua retirement account (IRA) or Archer MSA, or any other person approved by the IRS Specific Instructions Artice XI Artice XI and any that foow it may incorporate additiona provisions that are agreed to by the account owner and custodian The additiona provisions may incude, for exampe, definitions, restrictions on roover contributions from HSAs or Archer MSAs (requiring a roover not ater than 60 days after receipt of a distribution and imited to one roover during a one-year period), investment powers, voting rights, excupatory provisions, amendment and termination, remova of custodian, custodian's fees, state aw requirements, treatment of excess contributions, distribution procedures (incuding frequency or minimum doar amount), use of debit, credit, or stored-vaue cards, return of mistaken distributions, and descriptions of prohibited transactions Attach additiona pages if necessary Woters Kuwer Financia Services - Bankers Systems* Form HSA-CUSORGLZ Rev 2/1/2007 (page 5 of 8)

7 HEALTH SAVINGS ACCOUNT DISCLOSURE STATEMENT This Discosure Statement This Discosure Statement provides you, or your beneficiaries after your death, with a summary of the rues and reguations governing this HSA Definitions The Heath Savings Custodia Account agreement contains a detaied definitions section The definitions found in such section appy to this Agreement It refers to you as the account owner, and us as the custodian References to "you," "your," and "HSA owner" wi mean the account owner, and "we," "us," and "our" wi mean the custodian Upon your death, your spouse beneficiary, if appicabe, becomes "you" for purposes of this Discosure Statement In the event you appoint a third party, or have a third party appointed on your behaf to hande certain transactions affecting your HSA, such third party wi be considered your agent and, therefore, "you" for purposes of this Discosure Statement Additionay, references to "HSA" wi mean the custodia account For Additiona Guidance It is in your best interest to seek the guidance of a tax or ega professiona before competing any HSA estabishment documents Your first reference for questions concerning your HSA shoud be Interna Revenue Code (IRC) Section 223, other reevant IRC sections, and a additiona Interna Revenue Service (IRS) guidance; IRS pubications that incude information about HSAs; any additiona provisions or amendments to such documents; and this Discosure Statement For more information, you can aso refer to the instructions to your federa income tax return, your oca IRS office, or the IRS's web site at wwwirsgov HSA Restrictions and Approva 1 Heath Savings Custodia Account Agreement This Discosure Statement and the Heath Savings Custodia Account agreement, amendments, and additiona provisions, set forth the terms and conditions governing your HSA Such documents are the "Agreement" 2 Individua/Famiy Benefit This HSA must be for the excusive benefit of you, your spouse, and your dependents and upon your death, your beneficiaries The HSA must be estabished in your name and not in the name of your beneficiary, iving trust, or another party or entity 3 Beneficiary Designation By competing the appropriate section on the corresponding Heath Savings Account Appication you may designate any person(s) as your beneficiary to receive your HSA assets upon your death You may aso change or revoke an existing designation in such manner and in accordance with such rues as your HSA custodian prescribes for this purpose If there is no beneficiary designation on fie at the time of your death, or if none of the beneficiaries on fie are aive at the time of your death, your HSA assets wi be paid to your estate Your HSA custodian may rey on the atest beneficiary designation on fie at the time of your death, wi be fuy protected in doing so, and wi have no iabiity whatsoever to any person making a caim to the HSA assets under a subsequenty fied designation or for any other reason 4 Cash Contributions Reguar or annua HSA contributions must be in cash, which may incude a check, money order, or wire transfer It is within our discretion to accept in-kind contributions for roovers, transfers, or simiar transactions 5 HSA Custodian An HSA custodian must be a bank, an insurance company, a person previousy approved by the IRS to be a trustee of an individua retirement account (IRA) or Archer Medica Savings Account (MSA) or any other person approved by the IRS 6 Prohibition Against Life Insurance and Comminging None of your HSA assets may be invested in ife insurance contracts, or comminged with other property, except in a common trust fund or common investment fund 7 Nonforfeitabiity The assets in your HSA are not forfeitabe 8 Tax-Free Roovers You may be eigibe to make a roover contribution of your HSA or Archer MSA distribution, in cash or in kind, to an HSA These and other potentia roovers to and from HSAs are described in greater detai esewhere in this Discosure Statement 9 No Prohibited Transactions If you engage in a prohibited transaction, the HSA oses its tax exempt status as of the first day of the year You must incude the fair market vaue of your HSA as of that first day in your gross income for the year during which the prohibited transaction occurred, and pay a appicabe taxes and penaties 10 No Pedging If you pedge a or a portion of your HSA as security for a oan, the portion pedged wi be treated as a distribution to you, and the taxabe portion wi be incuded in gross income, and may be subject to the additiona 10 percent tax 11 IRS Approva of Form This Agreement incudes an IRS Forms 5305 series agreement This IRS document has been approved by the IRS This approva is not a determination of its merits, and not an endorsement of the investments provided by us or the operation of the HSA 12 State Laws State aws may affect your HSA in certain situations, incuding deductions, beneficiary designations, agency reationships, consent, taxes, tax withhoding, and reporting HSA Eigibiity 1 Eigibiity for an HSA You are an eigibe individua and may make or receive an HSA reguar contribution if, with respect to any month, you: a b are covered under a high-deductibe heath pan (HDHP); are not covered by any other type of heath pan that is not an HDHP (with certain exceptions for pans providing preventive care and imited types of permitted insurance and permitted coverage); are not enroed in Medicare; and may not be caimed as a dependent on another person's tax c d return 2 High-Deductibe Heath Pan Generay, an HDHP is a heath pan that satisfies certain requirements with respect to deductibes and out-of-pocket expenses For purposes of this HSA, a high-deductibe heath pan is a pan with an annua deductibe of at east $1,100 for sef-ony coverage or $2,200 for famiy coverage These amounts are for 2007 and are subject to annua cost-of-iving adjustments (COLAs) For HSA purposes, the high-deductibe heath pan must imit out-of-pocket expenses For 2007, the maximum out-of-pocket expenses, which incude money appied to your deductibe and your coinsurance for covered charges, must be no more than $5,500 for sef-ony coverage or $11,000 for famiy coverage These amounts are subject to annua COLAs IRS Notice provides a safe harbor for the absence of a preventive care deductibe It states that a pan sha not fai to be treated as an HDHP by reason of faiing to have a deductibe for preventive care An HDHP may therefore provide preventive care benefits without a deductibe or with a deductibe beow the minimum annua deductibe 3 Permitted Insurance You are eigibe for an HSA if you have coverage for any benefit provided by permitted insurance See IRS Notice for further information In addition, you are eigibe for an HSA if you have coverage (whether provided through insurance or otherwise) for accidents, disabiity, denta care, vision care, or ong-term care If a pan that is intended to be an HDHP is one in which substantiay a of the coverage of the pan is through permitted insurance or other coverage described in IRS Notice , it is not an HDHP Woters Kuwer Financia Services - Bankers Systems* Form HSA-CUSORGLZ Rev 2/1/2007 (page 6 of 8)

8 HSA Contributions 1 Who Can Make Reguar or Annua Contributions If you meet the eigibiity requirements for an HSA, you, your empoyer, your famiy members, or any other person (incuding nonindividuas) may contribute to your HSA This is true whether you are sef-empoyed or unempoyed 2 Reguar or Annua Contributions The maximum annua contribution to an HSA is the sum of the imits determined separatey for each month, based on status, eigibiity, and heath pan coverage as of the first day of the month The maximum monthy contribution for eigibe individuas is 1/12 of the annua contribution imit For eigibe individuas with sef-ony coverage under an HDHP, the 2007 annua contribution imit is $2,850 For eigibe individuas with famiy coverage under an HDHP, the annua contribution imit is $5,650 These amounts are subject to annua COLAs Beginning in 2007, a provision is avaiabe if you are an eigibe individua during the ast month of the tax year, but are not an eigibe individua for a months of the tax year If so, you are treated as an eigibe individua for a months of such tax year and may contribute up to such year's annua contribution imit A testing period appies The testing period for this provision begins with the ast month of the contribution year and ends on the ast day of the 12th month foowing such month If you do not continue to be an eigibe individua for the entire testing period, uness you die or become disabed, the amount of the contribution for the months you were not originay eigibe wi be incudabe in gross income for the year of the faiure and is subject to a 10 percent penaty tax Aso beginning in 2007, if you are an eigibe individua, you may eect to take a quaified HSA funding distribution from your IRA to the extent such distribution is contributed to your HSA in a direct trustee-to-trustee transfer This amount is aggregated with a other annua contributions and is subject to your annua contribution imit A quaified HSA funding distribution eection is irrevocabe and is generay avaiabe once in your ifetime A testing period appies The testing period for this provision begins with the month of the contribution to your HSA and ends on the ast day of the 12th month foowing such month If you are not an eigibe individua for the entire testing period, uness you die or become disabed, the amount of the contribution made under this provision wi be incudabe in gross income for the tax year of the month you are not an eigibe individua, and is subject to a 10 percent penaty tax If you have more than one HSA, the aggregate annua contributions to a the HSAs are subject to the contribution imit This imit is decreased by the aggregate contributions to an Archer MSA The same annua contribution imit appies whether the contributions are made by you, your empoyer, your famiy members, or any other person (incuding nonindividuas) Contributions may be made on your behaf even if you have no compensation or if the contributions exceed your compensation 3 Catch-up Contributions Catch-up contributions are HSA contributions made in addition to any reguar HSA contributions You are eigibe to make catch-up contributions if you meet the eigibiity requirements for reguar contributions and are age 55 or oder by the end of your taxabe year and not enroed in Medicare As with the annua contribution imit, the catch-up contribution is computed on a monthy basis The chart that foows shows these additiona amounts Tax Year and ater Catch-up Amount $ $ $ 1, Woters Kuwer Financia Services - Bankers Systems* Form HSA-CUSORGLZ Rev 2/1/ One or Both Spouses Have Famiy Coverage You and your spouse are treated as having famiy coverage if either of you has famiy coverage The contribution imit is divided equay between you and your spouse, uness each of you agree on a different division The famiy coverage imit is reduced further by any contribution to an Archer MSA However, each of you may make the catch-up contributions without exceeding the famiy coverage imit 5 Contribution Deductibiity a Your Contributions Contributions made by you to an HSA, which do not exceed the maximum annua contribution amount, are deductibe by you when determining your adjusted gross income You are not required to itemize deductions in order to take this deduction However, you cannot aso deduct the contributions as medica expenses under section 213 Contributions by famiy members or any other person (incuding nonindividuas) on your behaf are aso deductibe by you A contribution from an IRA is not deductibe b Empoyer Contributions Empoyer contributions are treated as empoyer-provided coverage for medica expenses under an accident or heath pan and are excudabe from your gross income The empoyer contributions are not subject to withhoding from wages for income tax or subject to the Federa Insurance Contributions Act (FICA), the Federa Unempoyment Tax Act (FUTA), or the Rairoad Retirement Tax Act Contributions to your HSA through a cafeteria pan are treated as empoyer contributions You cannot deduct empoyer contributions on your federa income tax return as HSA contributions or as medica expense deductions under section Contribution Deadine You may make reguar and catch-up HSA contributions any time for a taxabe year up to and incuding your federa income tax return due date, excuding extensions, for that taxabe year The due date for most taxpayers is Apri 15 Moving Assets To and From HSAs There are a variety of transactions that aow you to move assets to and from your HSA We have soe discretion on whether we wi accept, and how we wi process, movements of assets to and from HSAs We or the other financia organization invoved in the transaction may require documentation for such activities 1 HSA-to-HSA Transfers You may transfer a or a portion of your HSA assets from one HSA to another HSA An HSA transfer means that the HSA assets move from one HSA to another HSA in a manner that prevents you from cashing or iquidating the HSA assets, or even depositing the assets anywhere except in the receiving HSA You may be required to compete a transfer authorization form prior to transferring your HSA assets 2 Archer MSA-to-HSA Transfers A transfer of Archer MSA assets to an HSA is permitted However, HSA assets cannot be transferred to an Archer MSA 3 HSA-to-HSA Roovers An HSA roover is another way to move assets tax-free between HSAs You may ro over a or a portion of your HSA assets by taking a distribution from an HSA and recontributing it as a roover contribution into the same or another HSA Roovers to HSAs are not aowed from traditiona or Roth IRAs and empoyer-sponsored retirement pans You must report your HSA roover to the IRS on your federa income tax return Your contribution may ony be designated as a roover if the HSA distribution is deposited within 60 caendar days foowing the date you receive the distributed assets You are imited to one roover per HSA per 12 months The distributing and receiving HSA, incuding the HSA assets roed over, are subject to this (page 7 of 8)

9 12-month rue The 12-month period begins on the day after you receive a distribution that wi be propery roed over into an HSA 4 Archer MSA-to-HSA Roovers Roovers from an Archer MSA to an HSA are permitted However, HSA assets cannot be roed over to an Archer MSA The distributing MSA and receiving HSA, incuding the MSA assets roed over, are subject to the 12-month rue 5 Heath Reimbursement Arrangement (HRA)/Heath Fexibe Spending Account (FSA)-to-HSA Roovers You may be aowed to ro over assets from your HRA or heath FSA to an HSA The roover from your HRA or heath FSA must be contributed by the empoyer directy to your HSA This provision is avaiabe through tax-year 2011 if you are an eigibe individua A testing period appies The testing period for this provision begins with the month of the contribution to your HSA and ends on the ast day of the 12th month foowing such month If you are not an eigibe individua for the entire testing period, uness you die or become disabed, the amount of the contribution made under this provision wi be incudabe in gross income for the tax year of the month you are not an eigibe individua, and is subject to a 10 percent penaty tax HSA Distributions You or, after your death, your beneficiary may take an HSA distribution, in cash or in kind based on our poicies, at any time However, depending on the timing and amount of your distribution you may be subject to income taxes and/or penaty taxes HSA custodians/trustees are not required to determine whether HSA distributions are used for quaified medica expenses 1 Remova of Excess Contributions You may withdraw a or a portion of your excess contribution and attributabe earnings by your federa income tax return due date, incuding extensions, for the taxabe year for which the contribution was made The excess contribution amount distributed wi not be taxabe, but the attributabe earnings on the contribution wi be taxabe in the year in which the distribution is received If you timey fie your federa income tax return, you may sti remove your excess contribution, pus attributabe earnings, as ate as October 15 for caendar year fiers 2 Quaified Medica Expenses Quaified medica expenses are expenses paid by you, your spouse, or your dependents for medica care as defined in section 213(d) (incuding nonprescription drugs as described in Revenue Ruing , IRB 559), but ony to the extent the expenses are not covered by insurance or otherwise The quaified medica expenses must be incurred ony after the HSA has been estabished 3 Death Upon your death, any baance remaining in your HSA becomes the property of the beneficiaries named in the HSA agreement a Spouse If your spouse is the beneficiary of your HSA, the HSA becomes his/her HSA as of the date of your death We may require your spouse to transfer the assets to an HSA of his/her own Your spouse is subject to income tax ony to the extent distributions from your HSA are not used for quaified medica expenses b Nonspouse If your beneficiary is not your spouse, the HSA ceases to be an HSA as of the date of your death If your beneficiary is your estate, the fair market vaue of your HSA as of the date of your death is taxabe on your fina return For other beneficiaries, the fair market vaue of your HSA is taxabe to them in the tax year that incudes such date For such a person (except your estate), this amount is reduced by any payments from the HSA made for your quaified medica expenses, if paid within one year after your death Federa Income Tax Status of Distributions 1 Taxation Distributions from your HSA used excusivey to pay for quaified medica expenses of you, your spouse, or your dependents are excudabe from gross income In genera, amounts in an HSA can be used for quaified medica expenses and wi be excudabe from gross income even if you are not currenty eigibe for contributions to the HSA However, any amount of the distribution not used excusivey to pay for quaified medica expenses of you, your spouse, or your dependents is incudabe in your gross income and is subject to an additiona 10 percent tax on the amount incudabe, except in the case of distributions made after your death, your disabiity, or your attainment of age 65 HSA distributions which are not roed over wi be taxed as income in the year distributed, uness they are used for quaified medica expenses You may aso be subject to state or oca taxes and withhoding on your HSA distributions 2 Earnings Earnings, incuding gains and osses, on your HSA wi not be subject to federa income taxes unti they are considered distributed 3 Ordinary Income Taxation Your taxabe HSA distribution is usuay incuded in gross income in the distribution year Estate and Gift Tax The designation of a beneficiary to receive HSA distributions upon your death wi not be considered a transfer of property for federa gift tax purposes Upon your death, the vaue of a assets remaining in your HSA wi usuay be incuded in your gross estate for estate tax purposes, regardess of the named beneficiary or manner of distribution There is no specific estate tax excusion for assets hed within an HSA Federa Income Tax Withhoding If federa withhoding is appicabe, the custodian may require the competion of a withhoding eection document Annua Statements Each year we wi furnish you and the IRS with IRS-required statements refecting the activity in your HSA Federa Tax Penaties Severa tax penaties may appy to your various HSA transactions, and are in addition to any federa, state, or oca taxes Federa penaties and excise taxes are generay reported and remitted to the IRS aong with your federa income tax return The penaties may incude any of the foowing taxes: 1 Additiona 10 Percent Tax Any amount of a distribution not used excusivey to pay for quaified medica expenses of you, your spouse, or your dependents is subject to an additiona 10 percent tax on the amount incudabe in your gross income, except in the case of distributions made after your death, your disabiity, or your attainment of age 65 In addition, any faiure to meet a required testing period resuting in amounts incudabe in gross income wi make such amounts subject to an additiona 10 percent tax 2 Excess Contribution Penaty Tax If a contribution to your HSA exceeds the amount you are eigibe for, you have an excess contribution, which is subject to a 6 percent excise tax The excise tax appies each year that the excess contribution remains in your HSA If you timey fie your federa income tax return, you may sti remove your excess contribution, pus attributabe earnings, as ate as October 15 for caendar year fiers Woters Kuwer Financia Services - Bankers Systems* Form HSA-CUSORGLZ Rev 2/1/2007 (page 8 of 8)