Fillable Health Savings Account Power of Attorney Form (HRC Total Solutions)

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Health Savings Account Power of Attorney Form (HRC Total Solutions)

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The Health Savings Account Power of Attorney Form (HRC Total Solutions) form is 2 pages long and contains:

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29 other fields

Country of origin: US
File type: PDF

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HSA_Power of Attorney Form_2020.1 Page 1 of 2

Health Savings Account Power of Attorney Form

If you have any questions about HSAs or completing this form, please contact Customer Service at (603) 647-1147 Ext. 1.

1. Complete all sections of this form.

2. Signatures must be notarized.

3. Email, mail or fax completed form to:

Email: customerservice@hrcts.com

Address: 111 Charles Street, Manchester, NH 03101

Fax: 1-866-978-7868

*Required Fields

Part I Consumer Information

*Consumer Name (First, MI, Last) *Employer Name (If sponsored by an employer plan)

*Birth Date (MM/DD/YYYY) *

Social Security Number

*Day Telephone

Part II Power of Attorney Designation

* Attorney-in-fact Name (First, MI, Last)

*Birth Date (MM/DD/YYYY) *

Social Security Number

*Day Telephone

*Address

*City *State *Zip

HRC Total Solutions is hereby authorized to recognize the signature subscribed below in the payment of funds or transactions of

any business for this account. All transactions shall be governed by applicable laws and the Health Savings Account Custodian

Agreement. To the extent allowed by law, this authorization shall survive my disability or incapacity, and shall remain in effect until

HRC Total Solutions receives written notice of revocation and a reasonable opportunity to act on such notice.

Signature

By signing below, I authorize the attorney-in-fact identified above to perform any act I may perform pursuant to my HSA Custodial

Agreement with HRC Total Solutions and WEX Inc. This Power of Attorney is effective upon my signing. This authorization

includes, for example, the ability to: (1) endorse, cash, or deposit checks or other items payable to my order, (2) withdraw funds

from this account via any means allowed for this account, including but not limited to checks, ACH and wire transfers; and (3) give

instructions for the handling of any and all matters in connection with this account. I understand the powers I give to my attorney-

in-fact, and any limitations on those powers are between the attorney-in-fact and me, even if HRC Total Solutions have express

written notice of those powers. I agree to hold HRC Total Solutions and WEX Inc., harmless and be responsible for any damages

or costs incurred due to my HSA Administrator’s reliance on this Power of Attorney.

*Signature of HSA Account Holder *Date

*Signature of Attorney-in-fact *Date

HSA_Power of Attorney Form_2020.1 Page 2 of 2

*Notary to complete

Subscribed and sworn to before me this ______________ day of ____________, 20____

Notary Public Signature: ____________________________________________________________

Revocation of Power of Attorney

I hereby revoke the appointment named Power of Attorney and have notified them of this change. I understand that HRC Total

Solutions and WEX Inc. may charge the account for the amount of any check or pre-authorized transactions dated on or before

this date if they have been authorized by my attorney-in-fact.