DESIGNATION OF
BENEFICIARY(IES)
I designate the individual(s) named below as my primary and secondary Benefi ciary(ies) of this plan. I revoke all prior Benefi ciary designations, if any, made by
me. I understand that I may change or add Benefi ciaries at any time by completing and delivering the proper form to the Custodian. A secondary Benefi ciary’s
interest shall begin only upon the death or disclaimer of all primary benefi ciaries. If any primary or secondary Benefi ciary dies before me, his or her interest
shall terminate completely, and the share of any remaining Benefi ciary of the same class (primary or secondary respectively) shall be increased on a pro rata
basis. If neither “Primary” or “Secondary” is marked on this designation form by the name of a Benefi ciary, the Benefi ciary will be considered to be a Primary
Benefi ciary. This designation applies to all accounts open under this plan, either now or in the future.
The following individual(s) shall be my Benefi ciary(ies):
Primary Secondary Name
Address
Social Security Number
Date of Birth
Relationship
Primary Secondary Name
Address
Social Security Number
Date of Birth
Relationship
Primary Secondary Name
Address
Social Security Number
Date of Birth
Relationship
SPOUSAL
CONSENT
Subject to your state’s
community or marital
property laws, if
applicable.
I am the spouse of the Health Savings Account holder. I agree to my spouse’s designation of a primary benefi ciary other than myself. I acknowledge
that I have received a fair and reasonable disclosure of my spouse’s property and fi nancial obligations. I also acknowledge that I have no claim
whatsoever against KeyBank National Association or its affi liates, offi cers, directors, employees or agents (collectively, “KeyBank”), for any
payment made to my spouse’s named Benefi ciary(ies). I further acknowledge that no tax or legal advice was given to me by KeyBank.
ACCOUNT HOLDER’S SPOUSE SIGNATURE DATE
WITNESS SIGNATURE DATE
PLAN
CERTIFICATIONS
AND
SIGNATURE
Important: Please read before signing.
I hereby adopt the Health Savings Account Plan referenced above and appoint KeyBank as Custodian. I certify that I have received a copy of the
applicable KeyBank Health Savings Account Custodial Agreement and any accompanying disclosures. I understand the terms and conditions that apply
to this HSA are contained in the Custodial Agreement and disclosure. I agree to be bound by those terms and conditions.
I assume complete responsibility for the tax consequences of any contribution (including rollover contributions) and distributions. I further certify that I
am responsible for:
1) Determining my eligibility to establish this HSA.
2) Determining that all contributions to my HSA meet the requirements of the Internal Revenue Code governing such contributions.
3) Determining whether any payments from the HSA are used for qualifi ed medical expenses.
I release, indemnify and hold KeyBank harmless from any and all liabilities, damages, costs, expenses, taxes, penalties or other claims which it may
incur for relying on this certifi cation in accepting this account.
I understand the following tax certifi cation applies to all accounts opened under this Agreement:
Certifi cation of Taxpayer Identifi cation Number
Under penalties of perjury, I certify that:
1. The number shown on this form is my correct taxpayer identifi cation number (or I am waiting for a number to be issued to me), and
2. I am not subject to backup withholding because: (a) I am exempt from backup withholding, or (b) I have not been notifi ed by the
Internal Revenue Service (IRS) that I am subject to backup withholding as a result of a failure to report all interest or dividends, or
(c) the IRS has notifi ed me that I am no longer subject to backup withholding, and
3. I am a U.S. citizen or other U.S. person (defi ned in the instructions), and
4. I am exempt from the Foreign Account Tax Compliance Act (FATCA).
Certifi cation Instructions: You must cross out item 2 above if you have been notifi ed by the IRS that you are currently subject to backup
withholding because you have failed to report all interest and dividends on your tax return.
If you are a foreign person, cross out the above Certifi cation section and U.S. Person on the line next to your signature below. Complete
the appropriate IRS Form W-8.
Instructions to IRS Form W-9 Request for Taxpayer Identifi cation Number are provided upon request.
The Internal Revenue Service does not require your consent to any provision of this document other than the certifi cations required to
avoid backup withholding.
SIGNATURE OF
U.S. PERSON DATE
ACCEPTANCE
BY
KEYBANK
The plan shall be deemed to have been accepted by KeyBank upon receipt of all necessary forms, properly completed.
AUTHORIZED KEYBANK SIGNATURE DATE
Form No. EF-88-2014 09/15
Page 2 of 2
This form must be forwarded to Health Saving Operations, mailcode NY-00-01-0180
®
KeyBank Health Savings Account (HSA)
Application and Adoption Agreement
