Fill - Free fillable Simplifier HEALTH SAVINGS ACCOUNT APPLICATION (Georgia's Own Credit Union) PDF form

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HEALTH SAVINGS ACCOUNT APPLICATION

PART 1. HSA OWNER

Name (First/MI/Last) _________________________________________

Address Line 1 ______________________________________________

Address Line 2 ______________________________________________

City/State/ZIP _______________________________________________

Social Security Number _______________________________________

Date of Birth ____________________ Phone _____________________

Email Address _______________________________________________

Account Number _____________________________________________

PART 2. HSA TRUSTEE

To be completed by the HSA trustee

Name ______________________________________________________

Address Line 1 _______________________________________________

Address Line 2 _______________________________________________

City/State/ZIP _______________________________________________

Phone _______________________ Organizaon Number ___________

 ThisisanamendmenttoanexisngHSA.

 ThisHSAcontainsmanagedinvestmentsasdescribedintheTrustee

ManagementofInvestmentseconoftheagreement.

PART 3. CONTRIBUTION INFORMATION

Contribuon Amount ___________________________ Contribuon Date ________________

CONTRIBUTION TYPE (Select one)

1. Regular (Includescatch-upcontribuonsaswellasqualiedHSAfundingdistribuonsfromanIRA)

Contribuon for Tax Year _________ (QualiedHSAfundingdistribuonsfromanIRAmustbemadeforthecurrenttaxyear)

2. Rollover (DistribuonfromanHSAorArcherMSAthatisbeingdepositedintothisHSA)

By selecng this transacon, I irrevocably designate this contribuon as a rollover.

3. Transfer (DirectmovementofassetsfromanHSAorArcherMSAintothisHSA)

PART 4. INVESTMENT AND DEPOSIT INFORMATION

INVESTMENT INFORMATION (Completethisseconasapplicable.)

Investment Descripon Quanty or Amount Investment Number Term or Maturity Date Interest Rate

__________________________________________________ ________________________ ____________________ ____________________ ___________

DEPOSIT METHOD

Cash or Check (Ifthecontribuontypeistransfer,thecheckmustbefromanancialorganizaonmadepayabletothetrusteeforthisHSA.)

Internal Account

Account Number _____________________________________________ Type (e.g.,checking,savings,HSA) _______________________________

External Account (e.g.,EFT,ACH,wire) (Addionaldocumentaonmayberequiredandfeesmayapply.)

Name of Organizaon Sending the Assets ___________________________________________ Roung Number (Oponal) ___________________

Account Number _____________________________________________ Type (e.g.,checking,savings,HSA) _______________________________

Deposit Taken by ____________________________________

Simplifier®

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Checkhereifaddionalbeneciariesarelistedonanaachedaddendum. Total number of addendums aached to this HSA _________________

PART 5. BENEFICIARY DESIGNATION

I designate that upon my death, the assets in this account be paid to the beneciaries named below. The interest of any beneciary that predeceases

me terminates completely, and the percentage share of any remaining beneciaries will be increased on a pro rata basis. If no beneciaries are named,

my estate will be my beneciary.

I elect not to designate beneciaries at this me and understand that I may designate beneciaries at a later date.

PART 6. SPOUSAL CONSENT

Spousalconsentshouldbeconsideredifeitherthetrustortheresidence

oftheHSAownerislocatedinacommunityormaritalpropertystate.

CURRENT MARITAL STATUS

I Am Not Married – I understand that if I become married in the

future, I should review the requirements for spousal consent.

I Am Married – I understand that if I choose to designate a primary

beneciary other than or in addion to my spouse, my spouse should

sign below.

CONSENT OF SPOUSE

I am the spouse of the above-named HSA owner. I acknowledge that I have

received a fair and reasonable disclosure of my spouse’s property and

nancial obligaons. Because of the important tax consequences of giving

up my interest in this HSA, I have been advised to see a tax professional.

I hereby relinquish any interest that I may have

in this HSA and consent to

the beneciary designaon indicated above. I assume full responsibility for

any adverse consequences that may result.

X____________________________________________ ____________________

Signature of Spouse Date (mm/dd/yyyy)

X____________________________________________ ____________________

Signature of Witness Date (mm/dd/yyyy)

PART 7. SIGNATURES

Important: Pleasereadbeforesigning.

I understand the eligibility requirements for the type of HSA contribuon

I am making, and I state that I do qualify to make the contribuon. I have

received a copy of the Health Savings Account Applicaon, the 5305-B

Trust Account Agreement, and the Disclosure Statement. I understand

that the terms and condions that apply to this HSA are contained in this

Applicaon and the HSA Trust Account Agreement. I agree to be bound

by those terms and condions.

I assume complete responsibility for

• determining that I am eligible for an HSA each year I make a

contribuon,

• ensuring that all contribuons I make are within the limits set forth

by the tax laws, and

• the tax consequences of any contribuons (including rollover

contribuons) and distribuons.

X____________________________________________ ____________________

Signature of HSA Owner Date (mm/dd/yyyy)

X____________________________________________ ____________________

Signature of Witness Date (mm/dd/yyyy)

X____________________________________________ ____________________

Signature of Trustee Date (mm/dd/yyyy)

Name ______________________________________________________

Address ____________________________________________________

City/State/ZIP _______________________________________________

Date of Birth _________________ Relaonship ___________________

Tax ID (SSN/TIN) ____________________ Percent Designated ________

Name ______________________________________________________

Address ____________________________________________________

City/State/ZIP _______________________________________________

Date of Birth _________________ Relaonship ___________________

Tax ID (SSN/TIN) ____________________ Percent Designated ________

Name ______________________________________________________

Address ____________________________________________________

City/State/ZIP _______________________________________________

Date of Birth _________________ Relaonship ___________________

Tax ID (SSN/TIN) ____________________ Percent Designated ________

Name ______________________________________________________

Address ____________________________________________________

City/State/ZIP _______________________________________________

Date of Birth _________________ Relaonship ___________________

Tax ID (SSN/TIN) ____________________ Percent Designated ________

CONTINGENT BENEFICIARIES (Thetotalpercentagedesignatedmustequal100%.Ifmorethanonebeneciaryisdesignatedandnopercentages

areindicated,thebeneciarieswillbedeemedtoownequalsharepercentagesintheHSA.Thebalanceintheaccountwillbepayabletothesebeneciaries

ifallprimarybeneciarieshavepredeceasedtheHSAowner.)

Name ______________________________________________________

Address ____________________________________________________

City/State/ZIP _______________________________________________

Date of Birth _________________ Relaonship ___________________

Tax ID (SSN/TIN) ____________________ Percent Designated ________

Name ______________________________________________________

Address ____________________________________________________

City/State/ZIP _______________________________________________

Date of Birth _________________ Relaonship ___________________

Tax ID (SSN/TIN) ____________________ Percent Designated ________

Name ______________________________________________________

Address ____________________________________________________

City/State/ZIP _______________________________________________

Date of Birth _________________ Relaonship ___________________

Tax ID (SSN/TIN) ____________________ Percent Designated ________

Name ______________________________________________________

Address ____________________________________________________

City/State/ZIP _______________________________________________

Date of Birth _________________ Relaonship ___________________

Tax ID (SSN/TIN) ____________________ Percent Designated ________

PRIMARY BENEFICIARIES (Thetotalpercentagedesignatedmustequal100%.Ifmorethanonebeneciaryis designatedandnopercentagesare

indicated,thebeneciarieswillbedeemedtoownequalsharepercentagesintheHSA.)

Name of HSA Owner ______________________________________________________________, Account Number ____________________________

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The account owner named on the applicaon is establishing this health

savings account (HSA) exclusively for the purpose of paying or reimbursing

qualied 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 contribuons, he or she is eligible to

contribute to this HSA; specically, that he or she: (1) is covered under a

high deducble health plan (HDHP), (2) is not also covered by any other

health plan that is not an HDHP (with certain excepons for plans

providing prevenve care and limited types of permied insurance and

permied coverage), (3) is not enrolled in Medicare, and (4) cannot be

claimed as a dependent on another person’s tax return.

The account owner has assigned the trust account the sum indicated on

the applicaon.

The account owner and the trustee make the following agreement:

ARTICLE I

1. The trustee will accept addional cash contribuons 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 contribuons will

be accepted by the trustee for any account owner that exceeds the

maximum amount for family coverage plus the catch-up contribuon.

2. Contribuons for any tax year may be made at any me before the

deadline for ling the account owner’s federal income tax return for

that year (without extensions).

3. Rollover contribuons 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 contribuon

limit set forth in Arcle II.

4. Qualied HSA distribuons from a health exible spending arrangement

or health reimbursement arrangement must be completed in a

trustee-to-trustee transfer and are not subject to the maximum annual

contribuon limit set forth in Arcle II.

5. Qualied HSA funding distribuons from an individual rerement

account must be completed in a trustee-to-trustee transfer and are

subject to the maximum annual contribuon limit set forth in Arcle II.

ARTICLE II

1. For calendar year 2011, the maximum annual contribuon limit for an

account owner with single coverage is $3,050. This amount increases

to $3,100 in 2012. For calendar year 2011, the maximum annual

contribuon limit for an account owner with family coverage is $6,150.

This amount increases to $6,250 in 2012. These limits are subject to

cost-of-living adjustments aer 2012.

2. Contribuons to Archer MSAs or other HSAs count toward the

maximum annual contribuon limit to this HSA.

3. For calendar year 2009 and later years, an addional $1,000 catch-up

contribuon may be made for an account owner who is at least age 55

or older and not enrolled in Medicare.

4. Contribuons in excess of the maximum annual contribuon limit are

subject to an excise tax. However, the catch-up contribuons are not

subject to an excise tax.

ARTICLE III

It is the responsibility of the account owner to determine whether

contribuons to this HSA have exceeded the maximum annual contribuon

limit described in Arcle II. If contribuons to this HSA exceed the

maximum annual contribuon limit, the account owner shall nofy the

trustee that there exist excess contribuons to the HSA. It is the

responsibility of the account owner to request the withdrawal of the

excess contribuon and any net income aributable to such excess

contribuon.

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 collecbles as dened in secon 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 transacon with respect to this account (such as borrowing

or pledging the account or engaging in any other prohibited transacon

as dened in secon 4975).

ARTICLE VI

1. Distribuons of funds from this HSA may be made upon the direcon

of the account owner.

2. Distribuons from this HSA that are used exclusively to pay or

reimburse qualied medical expenses of the account owner, his or her

spouse, or dependents are tax-free. However, distribuons that are

not used for qualied medical expenses are included in the account

owner’s gross income and are subject to an addional 20 percent tax

on that amount. The addional 20 percent tax does not apply if the

distribuon is made aer the account owner’s death, disability, or

reaching age 65.

3. The trustee is not required to determine whether the distribuon is for

the payment or reimbursement of qualied medical expenses. Only

the account owner is responsible for substanang that the distribuon

is for qualied medical expenses and must maintain records sucient

to show, if required, that the distribuon is tax-free.

ARTICLE VII

If the account owner dies before the enre interest in the account is

distributed, the enre account will be disposed of as follows:

1. If the beneciary is the account owner’s spouse, the HSA will become

the spouse’s HSA as of the date of death.

2. If the beneciary is not the account owner’s spouse, the HSA will cease

to be an HSA as of the date of death. If the beneciary 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 nal return. For other

beneciaries, 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 informaon

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 arcle that may be added or incorporated in

this agreement, the provisions of Arcles I through VIII and this sentence

are controlling. Any addional arcle in this agreement that is inconsistent

with secon 223 or IRS published guidance will be void.

HEALTH SAVINGS TRUST ACCOUNT AGREEMENT

Form 5305-B under secon 223(a) of the Internal Revenue Code. FORM (December 2011)

Page 4 of 8

ARTICLE X

This agreement will be amended from me to me 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 on the

applicaon.

ARTICLE XI

11.01 Denions – In this part of this agreement (Arcle XI), the words

“you” and “your” mean the account owner. The words “we,” “us,”

and “our” mean the trustee. The word “Code” means the Internal

Revenue Code, and “regulaons” means the Treasury regulaons.

11.02 Noces and Change of Address – Any required noce regarding

this HSA will be considered eecve when we send it to the

intended recipient at the last address that we have in our records.

Any noce to be given to us will be considered eecve when we

actually receive it. You, or the intended recipient, must nofy us of

any change of address.

11.03 Representaons and Responsibilies – You represent and warrant

to us that any informaon you have given or will give us with

respect to this agreement is complete and accurate. Further, you

agree that any direcons you give us or acon you take will be

proper under this agreement, and that we are entled to rely upon

any such informaon or direcons. If we fail to receive direcons

from you regarding any transacon, if we receive ambiguous

direcons regarding any transacon, or if we, in good faith, believe

that any transacon requested is in dispute, we reserve the right to

take no acon unl further claricaon acceptable to us is received

from you or the appropriate government or judicial authority. We

will not be responsible for losses of any kind that may result from

your direcons to us or your acons or failures to act, and you

agree to reimburse us for any loss we may incur as a result of such

direcons, acons, or failures to act. We will not be responsible for

any penales, taxes, judgments, or expenses you incur in connecon

with your HSA. We have no duty to determine whether your

contribuons or distribuons comply with the Code, regulaons,

rulings, or this agreement. We have the right to require you to

provide, on a form provided by or acceptable to us, proof or

cercaon that you are eligible to contribute to this HSA,

including, but not limited to, proof or cercaon that you are

covered by an HDHP. In no event will we be responsible to

determine if contribuons made by your employer to your HSA

meet the requirements for comparable contribuons, the rules of

which are set forth in the Code and IRS published guidance.

We may permit you to appoint, through wrien noce acceptable

to us, an authorized agent to act on your behalf with respect to this

agreement (e.g., aorney-in-fact, executor, administrator,

investment manager), but we have no duty to determine the

validity of such appointment or any instrument appoinng such

authorized agent. In addion, we may allow you to designate an

authorized signer to perform various limited transacons on your

HSA as specied in a form provided by or acceptable to us. We may

rely upon this designaon unl such me, if any, that we receive a

wrien revocaon of the authorizaon. We will not be responsible

for losses of any kind that may result from direcons, acons, or

failures to act by your authorized agent and/or authorized signer,

and you agree to reimburse us for any loss we may incur as a result

of such direcons, acons, or failures to act by your authorized

agent and/or authorized signer.

You will have 60 days aer you receive any documents, statements,

or other informaon from us to nofy us in wring of any errors or

inaccuracies reected in these documents, statements, or other

informaon. If you do not nofy us within 60 days, the documents,

statements, or other informaon will be deemed correct and

accurate, and we will have no further liability or obligaon for such

documents, statements, other informaon, or the transacons

described therein.

By performing services under this agreement, we are acng as your

agent. Unless secon 11.06(b) of this agreement applies, you

acknowledge and agree that nothing in this agreement will be

construed as conferring duciary status upon us. We will not be

required to perform any addional services unless specically

agreed to under the terms and condions of this agreement, or as

required under the Code and the regulaons promulgated

thereunder with respect to HSAs. You agree to indemnify and hold

us harmless for any and all claims, acons, proceedings, damages,

judgments, liabilies, costs, and expenses, including aorney’s fees

arising from or in connecon with this agreement.

To the extent wrien instrucons or noces are required under this

agreement, we may accept or provide such informaon in any

other form permied by the Code or applicable regulaons

including, but not limited to, electronic communicaon.

11.04 Disclosure of Account Informaon – We may use agents and/or

subcontractors to assist in administering your HSA. We may release

nonpublic personal informaon regarding your HSA to such

providers as necessary to provide the products and services made

available under this agreement, and to evaluate our business

operaons and analyze potenal product, service, or process

improvements.

11.05 Service Fees – We have the right to charge an annual service fee or

other designated fees (e.g., a transfer, rollover, or terminaon fee)

for maintaining your HSA. In addion, we have the right to be

reimbursed for all reasonable expenses, including legal expenses,

we incur in connecon with the administraon of your HSA. We

may charge you separately for any fees or expenses, or we may

deduct the amount of the fees or expenses from the assets in your

HSA at our discreon. We reserve the right to charge any addional

fee aer giving you 30 days’ noce. Fees such as subtransfer agent

fees or commissions may be paid to us by third pares for

assistance in performing certain transacons with respect to this

HSA.

Any brokerage commissions aributable to the assets in your HSA

will be charged to your HSA. You cannot reimburse your HSA for

those commissions.

11.06 Investment of Amounts in the HSA –

a. Grantor Management of Investment. Unless the HSA or a

poron of the HSA is a managed HSA, you have exclusive

responsibility for and control over the investment of the assets of

your HSA. All transacons will be subject to any and all restricons

or limitaons, direct or indirect, that are imposed by our charter,

arcles of incorporaon, or bylaws; any and all applicable federal

and state laws and regulaons; the rules, regulaons, customs,

and usages of any exchange, market, or clearinghouse where the

transacon is executed; our policies and pracces; and this

agreement. We will have no discreon to direct any investment

in your HSA. We assume no responsibility for rendering

investment advice with respect to your HSA, nor will we oer any

opinion or judgment to you on maers concerning the value or

suitability of any investment or proposed investment for your

HSA. In the absence of instrucons from you, or if your

instrucons are not in a form acceptable to us, we will have the

right to hold any uninvested amounts in cash, and we will have

no responsibility to invest uninvested cash unless and unl

directed by you. We will not exercise the vong rights and other

shareholder rights with respect to investments in your HSA

unless you provide mely wrien direcons acceptable to us.

Page 5 of 8

You will select the investment for your HSA assets from those

investments that we are authorized by our charter, arcles of

incorporaon, or bylaws to oer and do in fact oer for HSAs

(e.g., term share accounts, passbook accounts, cercates of

deposit, money market accounts). We may, in our sole discreon,

make available to you, addional investment oerings, that will

be limited to publicly-traded securies, mutual funds, money

market instruments, and other investments that are obtainable

by us and that we are capable of holding in the ordinary course

of our business.

b. Trustee Management of Investment. If any poron of this HSA

is a managed HSA, as indicated on the applicaon or any other

supporng documentaon, we will manage the investment of

the applicable HSA assets. Accordingly, we can manage, sell,

contract to sell, grant, or exercise opons to purchase, convey,

exchange, transfer, abandon, improve, repair, insure, lease for

any term, and otherwise deal with all property, real or personal,

in your HSA in such manner, for such prices, and on such terms

and condions as we will decide.

We will have the power to do any of the following as we deem

necessary or advisable.

1. To invest your HSA assets in a single trust fund, and to collect

the income without disncon between principal and

income

2. To invest your HSA assets in a common trust fund or

common investment fund within the meaning of Code

secon 223(d)(1)(D)

3. To invest your HSA assets into savings instruments that we

oer

4. To invest your HSA assets in any other type of investment

permied by law, including, but not limited to, common or

preferred stock, open- or closed-end mutual funds, bonds,

notes, debentures, opons, U.S. Treasury bills, commercial

paper, or real estate

5. To hold any securies or other property under this agreement

in our own name, in the name of a nominee, or in bearer

form

6. To make, execute, acknowledge, and deliver any and all

documents of transfer and conveyance (including documents

for the transfer and conveyance of real estate), and any and

all instruments that may be necessary or appropriate to

carry out our powers

7. To employ suitable agents, aorneys, or other persons

8. To enter into lawsuits or sele any claims concerning the

assets in your HSA, and to be reimbursed for any expenses

or damages from you or your HSA assets

9. To exercise the vong rights and other shareholder rights

with respect to securies in your HSA, provided, however,

that we reserve the right to enter into a separate agreement

with you governing the exercise of vong and other

shareholder rights

10. To perform any and all acts that we deem necessary or

appropriate for the proper administraon of your HSA

All of the foregoing notwithstanding, our powers will be subject to

any and all restricons or limitaons, direct or indirect, that are

imposed by our charter, arcles of incorporaon, or bylaws; any

and all applicable federal and state laws and regulaons; the rules,

regulaons, customs, and usages of any exchange, market, or

clearing house where the transacon is executed; our policies and

pracces; and this agreement.

11.07 Beneciaries – If you die before you receive all of the amounts in

your HSA, payments from your HSA will be made to your

beneciaries. We have no obligaon to pay to your beneciaries

unl such me we are noed of your death by receiving a valid

death cercate.

You may designate one or more persons or enes as beneciary

of your HSA. This designaon can only be made on a form provided

by or acceptable to us, and it will only be eecve when it is led

with us during your lifeme. Each beneciary designaon you le

with us will cancel all previous designaons. The consent of your

beneciaries will not be required for you to revoke a beneciary

designaon. If you have designated both primary and conngent

beneciaries and no primary beneciary survives you, the

conngent beneciaries will acquire the designated share of your

HSA. If you do not designate a beneciary or if all of your primary

and conngent beneciaries predecease you, your estate will be

the beneciary.

If your surviving spouse acquires the interest in this HSA by reason

of being the beneciary at your death, this HSA (or in accordance

with rules established by the IRS, the relevant poron thereof) will

be treated as if the surviving spouse is the account owner.

If the beneciary is not your spouse, the HSA (or in accordance with

rules established by the IRS, the relevant poron thereof) will cease

to be an HSA as of the date of your death.

Upon learning of your death, we may, in our complete and sole

discreon, make a nal distribuon to a beneciary (other than

your spouse) of his or her interest in the HSA. This distribuon may

be made without the beneciary’s consent and may be placed in an

interest-bearing (or similar) account that we choose.

11.08 Terminaon of Agreement, Resignaon, or Removal of Trustee –

Either party may terminate this agreement at any me by giving

wrien noce to the other. We can resign as trustee at any me

eecve 30 days aer we send wrien noce of our resignaon to

you. Upon receipt of that noce, you must make arrangements to

transfer your HSA to another nancial organizaon. If you do not

complete a transfer of your HSA within 30 days from the date we

send the noce to you, we have the right to transfer your HSA

assets to a successor HSA trustee or custodian that we choose in

our sole discreon, or we may pay your HSA to you in a single sum.

We will not be liable for any acons or failures to act on the part of

any successor trustee or custodian, nor for any tax consequences

you may incur that result from the transfer or distribuon of your

assets pursuant to this secon.

If this agreement is terminated, we may charge to your HSA a

reasonable amount of money that we believe is necessary to cover

any associated costs, including but not limited to, one or more of

the following.

• Any fees, expenses, or taxes chargeable against your HSA

• Any penales or surrender charges associated with the early

withdrawal of any savings instrument or other investment in

your HSA

If we are a nonbank trustee required to comply with Regulaons

secon 1.408-2(e) and we fail to do so or we are not keeping the

records, making the returns, or sending the statements as are

required by forms or regulaons, the IRS may require us to

substute another trustee or custodian.

We may establish a policy requiring distribuon of the enre

balance of your HSA to you in cash or property if the balance of your

HSA drops below the minimum balance required under the

applicable investment or policy established.

Page 6 of 8

11.09 Successor Trustee – If our organizaon changes its name,

reorganizes, merges with another organizaon (or comes under the

control of any federal or state agency), or if our enre organizaon

(or any poron that includes your HSA) is bought by another

organizaon, that organizaon (or agency) will automacally

become the trustee or custodian of your HSA, but only if it is the type

of organizaon authorized to serve as an HSA trustee or custodian.

11.10 Amendments – We have the right to amend this agreement at any

me. Any amendment we make to comply with the Code and

related regulaons does not require your consent. You will be

deemed to have consented to any other amendment, unless within

30 days from the date we send the amendment, you nofy us in

wring that you do not consent.

11.11 Withdrawals or Transfers – All requests for withdrawal or transfer

will be in wring on a form provided by or acceptable to us. The

method of distribuon must be specied in wring or in any other

method acceptable to us. The tax idencaon number of the

recipient must be provided to us before we are obligated to make

a distribuon. Withdrawals will be subject to all applicable tax and

other laws and regulaons, including but not limited to possible

early distribuon penalty taxes, surrender charges, and withholding

requirements.

We may allow the return of mistaken distribuons if there is clear

and convincing evidence that the amounts distributed from the HSA

were because of a mistake of fact due to reasonable cause. In

determining whether this standard has been met, we may rely on

your representaon that the distribuon was, in fact, a mistake.

In no event will we restrict HSA distribuons to pay or reimburse

only your qualied medical expenses. We may, however, on a case-

by-case basis or as a maer of policy, place reasonable restricons

on both the frequency and the minimum amount of distribuons

from the HSA.

We may establish a policy whereby having a zero balance in your

HSA may not cause the HSA to be closed. At our discreon, future

contribuons may be made to the HSA unl you instruct us to close

the HSA.

11.12 Transfers from Other Plans – We can receive amounts transferred

to this HSA from the trustee or custodian of another HSA. In

addion, we can accept rollovers of an eligible amount from an

Archer MSA. We reserve the right not to accept any transfer or

rollover.

11.13 Liquidaon of Assets – We have the right to liquidate assets in your

HSA if necessary to make distribuons or to pay fees, expenses,

taxes, penales, or surrender charges properly chargeable against

your HSA. If you fail to direct us as to which assets to liquidate, we

will decide, in our complete and sole discreon, and you agree to

not hold us liable for any adverse consequences that result from

our decision.

11.14 Restricons on the Fund – Neither you nor any beneciary may sell,

transfer, or pledge any interest in your HSA in any manner

whatsoever, except as provided by law or this agreement.

The assets in your HSA will not be responsible for the debts,

contracts, or torts of any person entled to distribuons under this

agreement.

11.15 What Law Applies – This agreement is subject to all applicable

federal and state laws and regulaons. If it is necessary to apply any

state law to interpret and administer this agreement, the law of our

domicile will govern.

If any part of this agreement is held to be illegal or invalid, the

remaining parts will not be aected. Neither your nor our failure to

enforce at any me or for any period of me any of the provisions

of this agreement will be construed as a waiver of such provisions

or your right or our right thereaer to enforce each and every such

provision.

GENERAL INSTRUCTIONS

SeconreferencesaretotheInternalRevenueCode.

WHAT’S NEW

Addional Tax Increased – For tax years beginning aer December 31,

2010, the addional tax on distribuons not used for qualied medical

expenses increases from 10 percent to 20 percent.

PURPOSE OF FORM

Form 5305-B is a model trust account agreement that has been approved

by the IRS. An HSA is established aer the form is fully executed by both

the account owner and the trustee. The form can be completed at any

me during the tax year. This account must be created in the United States

for the exclusive benet of the account owner.

Do not le Form 5305-B with the IRS. Instead, keep it with your records.

For more informaon on HSAs, see Noce 2004-2, 2004-2 I.R.B. 269,

Noce 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

Idenfying Number – The account owner’s Social Security number will

serve as the idencaon 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 idencaon number

(EIN) is required for an HSA for which a return is led to report unrelated

business taxable income. An EIN is also required for a common fund

created for HSAs.

High Deducble Health Plan (HDHP) – For calendar year 2011, an HDHP

for self-only coverage has a minimum annual deducble of $1,200 and an

annual out-of-pocket maximum (deducbles, co-payments, and other

amounts, but not premiums) of $5,950. In 2012, the $1,200 minimum

annual deducble 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 deducble of $2,400 and an annual out-

of-pocket maximum of $11,900. In 2012, the $2,400 minimum annual

deducble remains the same and the annual out-of-pocket maximum

increases to $12,100. These limits are subject to cost-of-living adjustments

aer 2012.

Self-Only Coverage and Family Coverage Under an HDHP – Family

coverage means coverage that is not self-only coverage.

Qualied Medical Expenses – Qualied medical expenses are amounts

paid for medical care as dened in secon 213(d) for the account owner,

his or her spouse, or dependents (as dened in secon 152) but only to the

extent that such amounts are not compensated for by insurance or

otherwise. With certain excepons, health insurance premiums are not

qualied 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

rerement account (IRA) or Archer MSA, or any other person approved by

the IRS.

Page 7 of 8

REQUIREMENTS OF AN HSA

A. Cash Contribuons – Your contribuon must be in cash, unless it is a

rollover contribuon.

B. Maximum Contribuon – The total amount that may be contributed to

your HSA for any taxable year is the sum of the limits determined

separately for each month. The determinaon for each month is based

on whether, as of the rst day of such month, you are eligible to

contribute and whether you have self-only or family coverage under a

high deducble health plan (HDHP). If you have self-only coverage, the

maximum monthly contribuon is 1/12 of $3,100 (for 2012). If you have

family coverage, the maximum monthly contribuon is 1/12 of $6,250

(for 2012). These 2012 limits are subject to cost-of-living increases. In

addion, if you have aained age 55 before the close of the taxable

year, the annual contribuon limit is increased by an addional amount

not to exceed $1,000 each year. The annual limit is decreased by

aggregate contribuons made to an Archer MSA and by any qualied

HSA funding distribuons from an IRA deposited into the HSA.

If you become HSA-eligible aer the beginning of the year, you may

make a full year’s contribuon up to the statutory contribuon limit as

long as you maintain eligibility during the tesng period. The tesng

period begins the last month of the inial eligibility year and ends at

the end of the 12-month period following that month. If you do not

remain eligible during the tesng period, you must include in your

gross income the contribuons made for the months that you were not

otherwise eligible and pay a 10 percent penalty tax on the amount.

C. Contribuon Eligibility – You are an eligible individual for any month if

you (1) are covered under an HDHP on the rst day of such month; (2)

are not also covered by any other health plan that is not an HDHP and

that provides coverage for any benet covered under the HDHP (with

limited excepons); (3) are not enrolled in Medicare; and (4) are not

eligible to be claimed as a dependent on another person’s tax return.

In general, an HDHP is a health plan that sases certain requirements

with respect to deducbles and out-of-pocket expenses. Specically,

an HDHP has an annual deducble of at least $1,200 (for 2012) for self-

only coverage and at least $2,400 (for 2012) for family coverage. In

addion, the sum of the annual out-of-pocket expenses required to be

paid (deducbles, copayments, and amounts other than premiums)

cannot exceed $6,050 (for 2012) for self-only coverage and $12,100

(for 2012) for family coverage. All of these dollar amounts may be

adjusted annually for cost-of-living increases.

D. Nonforfeitability – Your interest in your HSA is nonforfeitable.

E. Eligible Trustees – The trustee of your HSA must be a bank, savings and

loan associaon, credit union, or a person or enty approved by the

Secretary of the Treasury.

F. Commingling Assets – The assets of your HSA cannot be commingled

with other property except in a common trust fund or common

investment fund.

G. Life Insurance – No poron of your HSA may be invested in life

insurance contracts.

INCOME TAX CONSEQUENCES OF ESTABLISHING AN HSA

A. HSA Deducbility – If you are eligible to contribute to your HSA for any

month during the taxable year, amounts contributed to your HSA are

deducble in determining adjusted gross income up to the maximum

contribuon limits discussed above. The deducon is allowed

regardless of whether you itemize deducons. Employer contribuons

to your HSA are excludable from your gross income and you cannot

deduct such amounts on your tax return as HSA contribuons.

B. Contribuon Deadline – The deadline for making an HSA contribuon

is your tax return due date (not including extensions). You may

designate a contribuon as a contribuon for the preceding taxable

year in a manner acceptable to us. For example, if you are a calendar-

year taxpayer and you make your HSA contribuon on or before your

tax ling deadline, your contribuon is considered to have been made

for the previous tax year if you designate it as such.

C. Excess Contribuons – An excess contribuon is any amount that is

contributed to your HSA that exceeds the amount that you are eligible

to contribute. If the excess is not corrected mely, an addional

penalty tax of six percent will be imposed upon the excess amount. The

procedure for correcng an excess is determined by the meliness of

the correcon as idened below.

1. Removal Before Your Tax Filing Deadline. An excess contribuon

may be corrected by withdrawing the excess amount, along with

the earnings aributable to the excess, before your tax ling

deadline, including extensions, for the year for which the excess

contribuon was made. An excess withdrawn under this method is

not taxable to you, but you must include the earnings aributable

to the excess in your taxable income in the year in which the

contribuon was made. The six percent excess contribuon penalty

tax will be avoided.

DISCLOSURE STATEMENT

SPECIFIC INSTRUCTIONS

Arcle XI – Arcle XI and any that follow it may incorporate addional

provisions that are agreed to by the account owner and trustee. The

addional provisions may include, for example, denions, restricons on

rollover contribuons from HSAs or Archer MSAs (requiring a rollover not

later than 60 days aer receipt of a distribuon and limited to one rollover

during a one-year period), investment powers, vong rights, exculpatory

provisions, amendment and terminaon, removal of trustee, trustee’s fees,

state law requirements, treatment of excess contribuons, distribuon

procedures (including frequency or minimum dollar amount), use of debit,

credit, or stored-value cards, return of mistaken distribuons, and

descripons of prohibited transacons. Aach addional pages if necessary.

Page 8 of 8

2. Removal Aer Your Tax Filing Deadline. If you are correcng an

excess contribuon aer your tax ling deadline, including

extensions, remove only the amount of the excess contribuon.

The six percent excess contribuon penalty tax will be imposed on

the excess contribuon for each year it remains in the HSA.

3. Carry Forward to a Subsequent Year. If you do not withdraw the

excess contribuon, you may carry forward the contribuon for a

subsequent tax year. To do so, you under-contribute for that tax

year and carry the excess contribuon amount forward to that year

on your tax return. The six percent excess contribuon penalty tax

will be imposed on the excess amount for each year that it remains

as an excess contribuon at the end of the year.

You must le IRS Form 5329 along with your income tax return to

report and remit any addional penalty taxes to the IRS.

D. Tax-Deferred Earnings – The investment earnings of your HSA are not

subject to federal income tax unl distribuons are made (or, in certain

instances, when distribuons are deemed to be made).

E. Taxaon of Distribuons – Distribuons taken from your HSA to pay for

qualied medical expenses or to reimburse you for qualied medical

expenses that you already paid are excluded from your gross income.

Qualied medical expenses are amounts you pay for medical care (as

dened in Internal Revenue Code Secon (IRC Sec.) 213(d)) for yourself,

your spouse, and your dependents (as dened in IRC Sec. 152), but only

to the extent that such amounts are incurred aer the HSA was

established and are not covered by insurance or otherwise. For a

general descripon of qualied medical expenses, refer to IRS

Publicaon 502, MedicalandDentalExpenses, available at www.irs.gov.

Distribuons made for purposes other than qualied medical expenses

are included in your gross income and are subject to an addional 20

percent penalty tax. This addional 20 percent penalty tax will apply

unless a distribuon is made on account of (1) aainment of age 65, (2)

death, or (3) disability.

Withdrawals from your HSA are not subject to federal income tax

withholding.

F. Rollovers – Your HSA may be rolled over to another HSA of yours or

may receive rollover contribuons, provided that all of the applicable

rollover rules are followed. Rollover is a term used to describe a tax-

free movement of cash or other property between any of your HSAs.

The general rollover rules are summarized below. These transacons

are oen complex. If you have any quesons regarding a rollover,

please see a competent tax advisor.

1. HSA or Archer MSA to HSA Rollovers. Assets distributed from your

HSA may be rolled over to an HSA of yours if the requirements of

IRC Sec. 223(f)(5) are met. A proper HSA to HSA rollover is

completed if all or part of the distribuon is rolled over not later

than 60 days aer the distribuon is received. You may make only

one rollover contribuon to an HSA during a 12-month period.

Assets distributed from your Archer MSA also may be rolled over to

your HSA. A proper Archer MSA to HSA rollover is completed if all

or part of the distribuon is rolled over not later than 60 days aer

the distribuon is received.

2. Wrien Elecon. At the me you make a rollover to an HSA, you

must designate in wring to the trustee your elecon to treat that

contribuon as a rollover. Once made, the rollover elecon is

irrevocable.

G. Qualied HSA Funding Distribuons – If you are eligible to contribute

to an HSA, you may be eligible to take a one-me, tax-free HSA funding

distribuon from your IRA and directly deposit it to your HSA. The

amount of the qualied HSA funding distribuon may not exceed the

maximum HSA contribuon limit in eect for the type of HDHP

coverage (i.e., self-only or family coverage) that you have at the me

of the deposit, and counts toward your HSA contribuon limit for that

year. If you do not remain HSA-eligible (for reasons other than death

or disability) for 12 months following the transacon, the amount of

the transacon is subject to taxaon and a 10 percent penalty tax. For

further detailed informaon, see IRS Publicaon 969, HealthSavings

AccountsandOtherTax-FavoredHealthPlans.

H. Beneciary Issues – If you die and your beneciary is your spouse, your

HSA (or the relevant poron thereof) will become your spouse’s HSA as

of the date of your death.

If your beneciary is not your spouse, the HSA (or the relevant poron

thereof) will cease to be an HSA as of the date of your death.

If the beneciary is your estate, the fair market value of the account as

of your date of death is taxable on your nal tax return. For other

beneciaries, the fair market value of the account is taxable to that

beneciary in the tax year that includes the date of death.

LIMITATIONS AND RESTRICTIONS

A. Deducon of Rollovers and Transfers – A deducon is not allowed for

rollover or transfer contribuons.

B. Prohibited Transacons – If you or your beneciary engage in a

prohibited transacon with your HSA, as described in IRC Sec. 4975,

your HSA will lose its tax-exempt status and you must include the value

of your account in your gross income for that taxable year. Overdrawing

your HSA is considered a prohibited transacon.

C. Pledging – If you pledge any poron of your HSA as collateral for a

loan, the amount so pledged will be treated as a distribuon and will

be included in your gross income for that year.

OTHER

A. IRS Plan Approval – The agreement used to establish this HSA has

been approved by the IRS. The IRS approval is a determinaon only as

to form. It is not an endorsement of the plan in operaon or of the

investments oered.

Important Informaon About Procedures for Opening a New Account –

To help the government ght the funding of terrorism and money

laundering acvies, federal law requires all nancial organizaons to

obtain, verify, and record informaon that idenes each person who

opens an account. Therefore, when you open an HSA, you are required

to provide your name, residenal address, date of birth, and

idencaon number. We may require other informaon that will

allow us to idenfy you.

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Simplifier HEALTH SAVINGS ACCOUNT APPLICATION (Georgia's Own Credit Union)

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