Form 5305-B (Rev. 12-2011)
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
Article XI may be used for any additional provisions. If no other provisions will be added, draw a line through this space. If provisions are added, they
must comply with the requirements of Article IX.
Account owner’s signature Date
Trustee’s signature Date
Witness’ signature
(Use only if signature of account owner or trustee is required to be witnessed.)
What's New
Additional Tax Increased. For tax years
beginning after December 31, 2010, the
additional tax on distributions not used for
qualified medical expenses increases from
10% to 20%.
General Instructions
Section references are to the Internal Revenue
Code.
Purpose of Form
Form 5305-B is a model trust account
agreement that has been approved by the
IRS. An HSA is established after the form is
fully executed by both the account owner and
the trustee. The form can be completed at any
time during the tax year. This account must
be created in the United States for the
exclusive benefit of the account owner.
Do not file Form 5305-B with the IRS.
Instead, keep it with your records. For more
information on HSAs, see Notice 2004-2,
2004-2 I.R.B. 269, Notice 2004-50, 2004-33
I.R.B. 196, Pub. 969, Health Savings
Accounts and Other Tax-Favored Health
Plans, and other IRS published guidance.
Definitions
Identifying Number. The account owner’s
social security number will serve as the
identification number of this HSA. 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. An
employer identification number (EIN) is
required for an HSA for which a return is filed
to report unrelated business taxable income.
An EIN is also required for a common fund
created for HSAs.
High Deductible Health Plan (HDHP). For
calendar year 2011, an HDHP for self-only
coverage has a minimum annual deductible of
$1,200 and an annual out-of-pocket
maximum (deductibles, co-payments and
other amounts, but not premiums) of $5,950.
In 2012, the $1,200 minimum annual
deductible remains the same and the annual
out-of-pocket maximum increases to $6,050.
For calendar year 2011, an HDHP for family
coverage has a minimum annual deductible
of $2,400 and an annual out-of-pocket
maximum of $11,900. In 2012, the $2,400
minimum annual deductible remains the same
and the annual out-of-pocket maximum
increases to $12,100. These limits are subject
to cost-of-living adjustments after 2012.
Self-only coverage and family coverage
under an HDHP. Family coverage means
coverage that is not self-only coverage.
Qualified medical expenses. Qualified
medical expenses are amounts paid for
medical care as defined in section 213(d) for
the account owner, his or her spouse, or
dependents (as defined in section 152) but
only to the extent that such amounts are not
compensated for by insurance or otherwise.
With certain exceptions, health insurance
premiums are not qualified medical expenses.
Trustee. A trustee of an HSA must be a
bank, an insurance company, a person
previously approved by the IRS to be a
trustee of an individual retirement account
(IRA) or Archer MSA, or any other person
approved by the IRS.
Specific Instructions
Article XI. Article XI and any that follow it may
incorporate additional provisions that are
agreed to by the account owner and trustee.
The additional provisions may include, for
example, definitions, restrictions on rollover
contributions from HSAs or Archer MSAs
(requiring a rollover not later than 60 days
after receipt of a distribution and limited to
one rollover during a one-year period),
investment powers, voting rights, exculpatory
provisions, amendment and termination,
removal of trustee, trustee’s fees, state law
requirements, treatment of excess
contributions, distribution procedures
(including frequency or minimum dollar
amount), use of debit, credit, or stored-value
cards, return of mistaken distributions, and
descriptions of prohibited transactions. Attach
additional pages if necessary.
Form 5305-B (Rev. 12-2011)