Form  5305-C                               Health Savings Custodial Account                                                   Do not file  
(Rev. October 2016)                                                                                                           with the Internal  
Department of the Treasury                 (Under section 223(a) of the Internal Revenue Code)                                Revenue Service 
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 
1.    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. 
2.    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). 
3.    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. 
4.    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. 
5.    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 
1.    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. 
3.    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. 
4.    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. 
3.    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) 

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 
1. 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                                       Definitions                                      Qualified medical expenses. Qualified  
                                                                                                  medical expenses are amounts paid for  
Additional Tax Increased. For tax years          Identifying Number.  The account owner’s         medical care as defined in section 213(d) for  
beginning after December 31, 2010, the           social security number will serve as the         the account owner, his or her spouse, or  
additional tax on distributions not used for     identification number of this HSA. For married   dependents (as defined in section 152) but  
qualified medical expenses increases from        persons, each spouse who is eligible to open     only to the extent that such amounts are not  
10% to 20%.                                      an HSA and wants to contribute to an HSA         compensated for by insurance or otherwise.  
                                                 must establish his or her own account. An        With certain exceptions, health insurance  
General Instructions                             employer identification number (EIN) is          premiums are not qualified medical expenses. 
Section references are to the Internal Revenue   required for an HSA for which a return is filed  
Code.                                            to report unrelated business taxable income.     Custodian. A custodian of an HSA must be a  
                                                 An EIN is also required for a common fund        bank, an insurance company, a person  
Purpose of Form                                  created for HSAs.                                previously approved by the IRS to be a  
                                                                                                  custodian of an individual retirement account  
Form 5305-C is a model custodial account         High Deductible Health Plan (HDHP). For          (IRA) or Archer MSA, or any other person  
agreement that has been approved by the          calendar year 2011, an HDHP for self-only        approved by the IRS. 
IRS. An HSA is established after the form is     coverage has a minimum annual deductible of 
fully executed by both the account owner and     $1,200 and an annual out-of-pocket               Specific Instructions 
the custodian. The form can be completed at      maximum (deductibles, co-payments and  
any time during the tax year. This account       other amounts, but not premiums) of $5,950.      Article XI. Article XI and any that follow it  
must be created in the United States for the     In 2012, the $1,200 minimum annual               may incorporate additional provisions that are 
exclusive benefit of the account owner.          deductible remains the same and the annual       agreed to by the account owner and  
Do not file Form 5305-C with the IRS.            out-of-pocket maximum increases to $6,050.       custodian. The additional provisions may  
Instead, keep it with your records. For more     For calendar year 2011, an HDHP for family       include, for example, definitions, restrictions  
information on HSAs, see Notice 2004-2,          coverage has a minimum annual deductible of      on rollover contributions from HSAs or Archer  
2004-2 I.R.B. 269, Notice 2004-50, 2004-33       $2,400 and an annual out-of-pocket               MSAs (requiring a rollover not later than 60  
I.R.B. 196, Pub. 969, Health Savings             maximum of $11,900. In 2012, the $2,400          days after receipt of a distribution and limited  
Accounts and Other Tax-Favored Health            minimum annual deductible remains the same       to one rollover during a one-year period),  
Plans, and other IRS published guidance.         and the annual out-of-pocket maximum             investment powers, voting rights, exculpatory  
                                                 increases to $12,100. These limits are subject   provisions, amendment and termination,  
                                                 to cost-of-living adjustments after 2012.        removal of custodian, custodian’s fees, state  
                                                                                                  law requirements, treatment of excess  
                                                 Self-only coverage and family coverage           contributions, distribution procedures  
                                                 under an HDHP. Family coverage means             (including frequency or minimum dollar  
                                                 coverage that is not self-only coverage.         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)