Fill - Free fillable Health Savings Custodial Account Oct-2016 Form-5305-C PDF form

Form 5305-C

(Rev. October 2016)

Department of the Treasury

Internal Revenue Service

Health Savings Custodial Account

(Under section 223(a) of the Internal Revenue Code)

Do not file

with the Internal

Revenue Service

Name of account owner Date of birth of account owner

Address of account owner (Street address, city, state, ZIP code)

Name of custodian Address or principal place of business of custodian

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 custodial account.

The account owner and the custodian make the following agreement:

Article I

The custodian 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 custodian for any account owner that exceeds the

maximum amount for family coverage plus the catch-up contribution.

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).

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.

Qualified HSA distributions from a health flexible spending arrangement or health reimbursement arrangement must be completed in a

trustee-to-trustee transfer and are not subject to the maximum annual contribution limit set forth in Article II.

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

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 2012. 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 2012. These limits are subject to cost-of-living adjustments after 2012.

2. Contributions to Archer MSAs or other HSAs count toward the maximum annual contribution limit to this HSA.

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.

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 custodian 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 custodial account is nonforfeitable.

Article V

1. No part of the custodial 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.

Neither the account owner nor the custodian 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 65.

3. The custodian 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. 38257X

Form 5305-C (Rev. 10-2016)

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

The account owner agrees to provide the custodian with information necessary for the custodian to prepare any report or return required by the

IRS.

2. The custodian 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

Custodian’s signature Date

Witness’ signature

(Use only if signature of account owner or custodian 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-C is a model custodial 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 custodian. 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-C 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.

Custodian. A custodian of an HSA must be a

bank, an insurance company, a person

previously approved by the IRS to be a

custodian 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

custodian. 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 custodian, custodian’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-C (Rev. 10-2016)

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