Health Savings Account

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1 Application Booklet Health Savings Account Delaware Charter Guarantee & Trust Company d/b/a Principal Trust Company

2 Table of Contents

3 Privacy Notice Protecting Your Privacy We Protect Information We Collect About You How We Collect Information How We Share Information With Others Accuracy of Information More Information

4 Please Complete the Following Information Application for Health Savings Account Beneficiary(ies): (If more than one Primary beneficiary is listed, make sure percentage is noted and totals 100%.) HSA Contributions: Important Note: In order to make contributions you are certifying that you are currently covered by a High Deductible Health Plan (HDHP) as defined in sec. 223(c)(2) of the Internal Revenue Code.

5 To be Completed by Representative Approval of Trustee

6 Instructions for Health Savings Accounts Consult With Your Attorney Disclosure Statement & Form 5305-B What is Required to Establish a Health Savings Account? Application & Form 5305-B Trust Installation and Notice Important Information on Float

7 Investments Contributions Mailing Instructions Records /2013

8 Disclosure Statement for Health Savings Accounts I. Your right to revoke your HSA II. Statutory Requirements

9 .

10 Line 3 Limitation Chart and Worksheet.

11

12

13 III. Additional Information

14 4. IRS Forms IRS Forms 5498-SA and 1099-SA are required to report contributions, additions, withdrawals or other activity for this account. We will complete and mail them to the IRS each year. To ensure accuracy, the cash statement from the Brokerage Firm must reflect the applicable tax year for each contribution and note whether the contribution is a regular or rollover contribution. 5. Arbitration You agree that all controversies between you and/or your beneficiaries and us and/or any of our officers, directors, or employees (present or former) concerning or arising from: The HSA that you maintain with us; Any transaction involving your HSA, whether or not such transactions occurred in such HSA or HSAs; or The construction, performance, or breach of the Form 5305-B provided by Principal Trust Company between us, whether such controversy arose prior, on, or subsequent to the date hereof, shall be determined under the commercial arbitration rules of the American Arbitration Association. Any disputes as to the arbitrability of a matter or the manner of such arbitration will be determined in such arbitration. The arbitration will be held in Wilmington, Delaware. 6. Arbitration Disclosures: a. Arbitration is final and binding on the parties, b. The parties are waiving their right to seek remedies in court, including the right to jury trial, c. Pre-arbitration discovery is generally more limited than and different from court proceedings, d. The arbitrator s award is not required to include factual findings or legal reasoning and any party s right to appeal or to seek modification of rulings by the arbitrators is strictly limited, e. The panel of arbitrators will consist of arbitrators from the American Arbitration Association, f. The arbitration will be under the commercial arbitration rules of the American Arbitration Association, g. The arbitration will be held in Wilmington, Delaware, h. Any disputes as to such arbitration or the manner thereof will be determined in such arbitration. The determination that any provision of the Form 5305-B and Disclosure Statement is not enforceable in accordance with its terms in a particular jurisdiction shall not affect the validity or enforceability of the remaining provisions of the Form 5305-B and Disclosure Statement generally or in any other jurisdiction or as to any other parties, but rather such unenforceable provisions shall be stricken or modified in accordance with such determination only as to such parties and the Form 5305-B and Disclosure Statement, as modified, shall continue to bind the specific parties involved therein and otherwise all other parties in unmodified form. Further information can be obtained from any district office of the Internal Revenue Service as applicable. Please check with your legal and/or tax counsel if you have any questions about how this information applies to your particular situation. 7. State Laws. The tax laws of certain states and local governments may be different from the federal tax laws for Health Savings Accounts. State and local laws are not covered in this disclosure statement. 8. Definition of Spouse. The term "spouse" as used in this disclosure statement is defined according to applicable law. 9. Legal Incapacity. If you (or after your death, your beneficiary) is legally incapacitated, then we may require that any and all rights that the incapacitated individual could exercise under the trust agreement or at law be exercised by the incapacitated individual s representative. We may rely on the authority and direction of such representative for all action taken with respect to the Health Savings Account. 10. IRS Information. The IRS has helpful information on Health Savings Accounts, including IRS Publication 969. This publication is available at any IRS district office, on line at or by calling TAX-FORM. TR Section /2013

15

16 Do not file (Rev. December 2011) with the Internal (Under section 223(a) of the Internal Revenue Code) Department of the Treasury Revenue Service Internal Revenue Service Name of account owner (grantor) Date of birth of account owner Identifying number (see instructions) Form 5305-B Health Savings Trust Account Address of account owner (Street address, city, state, ZIP code) Name of trustee Address or principal place of business of trustee The account owner named above 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. $ dollars in cash is assigned to this trust account. The account owner and the trustee make the following agreement: Article I 1. The trustee will accept additional cash contributions for the tax year made by the account owner or on behalf of the account owner (by an employer, family member, or any other person). No contributions will be accepted by the trustee for any account owner that exceeds the maximum amount for family coverage plus the catch-up contribution. 2. Contributions for any tax year may be made at any time before the deadline for filing the account owner s federal income tax return for that year (without extensions). 3. Rollover contributions from an HSA or an Archer Medical Savings Account (Archer MSA) (unless prohibited under this agreement) need not be in cash and are not subject to the maximum annual contribution limit set forth in Article II. 4. Qualified HSA distributions from a health flexible spending arrangement or health reimbursement arrangement must be completed in a trusteeto-trustee transfer and are not subject to the maximum annual contribution limit set forth in Article II. 5. Qualified HSA funding distributions from an individual retirement account must be completed in a trustee-to-trustee transfer and are subject to the maximum annual contribution limit set forth in Article II. Article II 1. For calendar year 2011, the maximum annual contribution limit for an account owner with single coverage is $3,050. This amount increases to $3,100 in For calendar year 2011, the maximum annual contribution limit for an account owner with family coverage is $6,150. This amount increases to $6,250 in These limits are subject to cost-of-living adjustments after Contributions to Archer MSAs or other HSAs count toward the maximum annual contribution limit to this HSA. 3. For calendar year 2009 and later years, an additional $1,000 catch-up contribution may be made for an account owner who is at least age 55 or older and not enrolled in Medicare. 4. Contributions in excess of the maximum annual contribution limit are subject to an excise tax. However, the catch-up contributions are not subject to an excise tax. Article III It is the responsibility of the account owner to determine whether contributions to this HSA have exceeded the maximum annual contribution limit described in Article II. If contributions to this HSA exceed the maximum annual contribution limit, the account owner shall notify the trustee that there exist excess contributions to the HSA. It is the responsibility of the account owner to request the withdrawal of the excess contribution and any net income attributable to such excess contribution. Article IV The account owner s interest in the balance in this trust account is nonforfeitable. Article V 1. No part of the trust funds in this account may be invested in life insurance contracts or in collectibles as defined in section 408(m). 2. The assets of this account may not be commingled with other property except in a common trust fund or common investment fund. 3. Neither the account owner nor the trustee will engage in any prohibited transaction with respect to this account (such as borrowing or pledging the account or engaging in any other prohibited transaction as defined in section 4975). Article 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 exclusively to pay or reimburse qualified medical expenses of the account owner, his or her spouse, or dependents are tax-free. However, distributions that are not used for qualified medical expenses are included in the account owner s gross income and are subject to an additional 20 percent tax on that amount. The additional 20 percent tax does not apply if the distribution is made after the account owner s death, disability, or reaching age The trustee is not required to determine whether the distribution is for the payment or reimbursement of qualified medical expenses. Only the account owner is responsible for substantiating that the distribution is for qualified medical expenses and must maintain records sufficient to show, if required, that the distribution is tax-free. Cat. No U Form 5305-B (Rev )

17 Form 5305-B (Rev ) Page 2 Article VII If the account owner dies before the entire interest in the account is distributed, the entire account will be disposed of as follows: 1. If the beneficiary is the account owner s spouse, the HSA will become the spouse s HSA as of the date of death. 2. If the beneficiary is not the account owner s spouse, the HSA will cease to be an HSA as of the date of death. If the beneficiary is the account owner s estate, the fair market value of the account as of the date of death is taxable on the account owner s final return. For other beneficiaries, the fair market value of the account is taxable to that person in the tax year that includes such date. Article VIII 1. The account owner agrees to provide the trustee with information necessary for the trustee to prepare any report or return required by the IRS. 2. The trustee agrees to prepare and submit any report or return as prescribed by the IRS. Article IX Notwithstanding any other article that may be added or incorporated in this agreement, the provisions of Articles I through VIII and this sentence are controlling. Any additional article in this agreement that is inconsistent with section 223 or IRS published guidance will be void. Article X This agreement will be amended from time to time to comply with the provisions of the Code or IRS published guidance. Other amendments may be made with the consent of the persons whose signatures appear below. Article XI Account Holder Application Beneficiary Brokerage Firm Code High-Deductible Health Plan (HDHP) Qualified Medical Expenses IRS Regulations Spouse Trustee Trust Trust Agreement

18 A. Contributions and Rollovers B. Investments

19 C. Distributions D. Beneficiaries

20 E. Trustee Compensation F. Amendment and Termination

21 G. Arbitration Provisions H. Miscellaneous

22 Word Usage Date Trustee s signature Date Witness signature (Use only if signature of account owner or trustee is required to be witnessed.) What's New persons, each spouse who is eligible to open dependents (as defined in section 152) but an HSA and wants to contribute to an HSA only to the extent that such amounts are not Additional Tax Increased. For tax years must establish his or her own account. An compensated for by insurance or otherwise. beginning after December 31, 2010, the employer identification number (EIN) is With certain exceptions, health insurance additional tax on distributions not used for required for an HSA for which a return is filed premiums are not qualified medical expenses. qualified medical expenses increases from to report unrelated business taxable income. 10% to 20%. Trustee. A trustee of an HSA must be a An EIN is also required for a common fund bank, an insurance company, a person created for HSAs. General Instructions previously approved by the IRS to be a High Deductible Health Plan (HDHP). For trustee of an individual retirement account Section references are to the Internal Revenue calendar year 2011, an HDHP for self-only (IRA) or Archer MSA, or any other person Code. coverage has a minimum annual deductible of approved by the IRS. Purpose of Form $1,200 and an annual out-of-pocket maximum (deductibles, co-payments and Specific Instructions Form 5305-B is a model trust account other amounts, but not premiums) of $5,950. agreement that has been approved by the Article XI. Article XI and any that follow it may In 2012, the $1,200 minimum annual IRS. An HSA is established after the form is incorporate additional provisions that are deductible remains the same and the annual fully executed by both the account owner and agreed to by the account owner and trustee. out-of-pocket maximum increases to $6,050. the trustee. The form can be completed at any The additional provisions may include, for For calendar year 2011, an HDHP for family time during the tax year. This account must example, definitions, restrictions on rollover coverage has a minimum annual deductible be created in the United States for the contributions from HSAs or Archer MSAs of $2,400 and an annual out-of-pocket exclusive benefit of the account owner. (requiring a rollover not later than 60 days maximum of $11,900. In 2012, the $2,400 after receipt of a distribution and limited to Do not file Form 5305-B with the IRS. minimum annual deductible remains the same one rollover during a one-year period), Instead, keep it with your records. For more and the annual out-of-pocket maximum investment powers, voting rights, exculpatory information on HSAs, see Notice , increases to $12,100. These limits are subject provisions, amendment and termination, I.R.B. 269, Notice , to cost-of-living adjustments after removal of trustee, trustee s fees, state law I.R.B. 196, Pub. 969, Health Savings Self-only coverage and family coverage requirements, treatment of excess Accounts and Other Tax-Favored Health under an HDHP. Family coverage means contributions, distribution procedures Plans, and other IRS published guidance. coverage that is not self-only coverage. (including frequency or minimum dollar Definitions Qualified medical expenses. Qualified amount), use of debit, credit, or stored-value Identifying Number. The account owner s medical expenses are amounts paid for cards, return of mistaken distributions, and social security number will serve as the medical care as defined in section 213(d) for descriptions of prohibited transactions. Attach identification number of this HSA. For married the account owner, his or her spouse, or additional pages if necessary.

23 Acceptance Fee Schedule of Standard Trustee Fees Effective January 1, 2012 Annual Fees Fees for Disbursement from Trust Other Charges In the event the fees become delinquent and it becomes necessary to collect the balance through the services of a collection agency, you will be held responsible for their fees.

24 WE LL GIVE YOU AN EDGE P.O. Box 8963, Wilmington, DE TR Delaware Charter Guarantee & Trust Company 12/2013

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