|Health Savings Account Disclosure|
Please print a copy of this page for your records.
You must agree with these terms at the bottom of this disclosure to access the application.
IMPORTANT ACCOUNT INFORMATION
NO BULL HEALTH SAVINGS ACCOUNT
|Interest Rate||Annual Percentage Yield||Effective Dates|
|1.00%||1.00%||5/01/13 - 5/31/13|
Rate Information - The interest rate and annual percentage yield are a monthly variable and may change at our discretion
Compounding Frequency Interest will be compounded monthly.
Crediting Frequency Interest will be credited into this account monthly.
Daily balance computation method Interest is calculated by the daily balance method which applies a daily periodic rate to the balance in the account each day.
Accrual of Interest on Noncash Deposits Interest will begin to accrue no later than the business day we receive credit for the deposit of noncash items (for example, checks) into your account.
Minimum Balance to Open The minimum balance required to open this account is $25.00.
Minimum Balance to Avoid a Fee - If your balance falls below $500.00 on any day in the month, your account will be subject to a $3.00 ACCOUNT MAINTENANCE FEE for that month.
Deposit Limitations You may make an unlimited number of deposits into your account.
Fees and Charges The following fees and charges apply to this account:
FOREIGN ATM DEBITS: There is a charge of $1.50 per withdrawal at ATMs not owned by our bank after the first three withdrawals per month.
ATM BALANCE INQUIRY: There is a charge of $1.00 per inquiry at ATMs not owned by our bank.
* Check writing convenience with the first box free of standard design checks.
* Free Visa Check Card and unlimited ATM usage free of charge at CNB ATM locations.
* Three free foreign ATM withdrawals per month.
* Monthly bank statements with images of checks and deposits for your records.
* Free Internet Banking Access with online bill pay (See Online Banking Internet Agreement for full disclosure).
* A low transfer out fee of only $35.00.
FUNDS AVAILABILITY POLICY
Your Ability to Withdraw Funds
This policy statement applies to “transaction” accounts. Transaction accounts, in general, are accounts which permit an unlimited number of payments to third persons and an unlimited number of telephone and preauthorized transfers to other accounts of yours with us. Feel free to ask us whether any of your other accounts might also be under this policy.
Our policy is to make funds from your cash and check deposits available to you on the first business day after the day we receive your deposit. Electronic direct deposits will be available on the day we receive the deposit. Once the funds are available, you can withdraw them in cash and we will use the funds to pay checks that you have written.
Please remember that even after we have made funds available to you and you have withdrawn the funds, you are still responsible for checks you deposit that are returned to us unpaid and for any other problems involving your deposits.
Determining the Availability of a Deposit
For determining the availability of your deposits, every day is a business day, except Saturdays, Sundays, and federal holidays. The length of the delay is counted in business days from the day of your deposit. If you make your deposit prior to 4:00 pm at our Lincoln Branch; 4:00 pm at our Motor Bank and 4:00 pm at our Main Bank, Monday through Friday on a business day that we are open, we will consider that day to be the day of your deposit. However if you make a deposit at the Lincoln Branch after 4:00 pm, the Motor Bank after 4:00 pm or the Main Bank after 4:00 pm, Monday through Friday or on a day we are not open, we will consider that the deposit was made on the next business day that we are open. If you make a deposit at an ATM before 6:00 pm on a business day that we are open, we will consider that day to be the day of your deposit. However, if you make a deposit at an ATM after 6:00 pm or on a day we are not open, we will consider that the deposit was made on the next business day we are open.
If we cash a check for you that is drawn on another bank, we may withhold the availability of the corresponding amount of funds that are already in one of your accounts. Those funds will be available at the time funds from the check we cashed would have been available if you had deposited it.
If we accept for deposit a check that is drawn on another bank, we may make funds from the deposit available for withdrawal immediately but delay your availability to withdraw a corresponding amount of funds that you have on deposit in another account with us. The funds in the other account would then not be available for withdrawal until the time periods that are described elsewhere in this disclosure for the type of check that you deposited.
Longer Delays May Apply
Case-By-Case Delays In some cases, we will not make all of the funds that you deposit by check available to you on the first business day after the day of your deposit. Depending on the type of check that you deposit, funds may not be available until the second business day after the day of your deposit. The first $200 of your deposits, however, may be available on the first business day.
If we are not going to make all of the funds from your deposit available on the first business day, after we receive your deposit, we will notify you at the time you make your deposit. We will also tell you when the funds will be available. If your deposit is not made directly to one of our employees, or if we decide to take this action after you have left the premises, we will mail you the notice by the first business day after we receive your deposit.
If you will need the funds from a deposit right away, you should ask us when the funds will be available.
Safeguard Exception Delays Funds you deposit by check may be delayed for a longer period under the following circumstances:
• We believe a check you deposit will not be paid.
• You deposit checks totaling more than $5,000.00 on any one day.
• You re-deposit a check that has been returned unpaid.
• You have overdrawn your account repeatedly in the last six months.
• There is an emergency, such as failure of computer or communications equipment.
We will notify you if we delay your ability to withdraw funds for any of these reasons, and we will tell you when the funds will be available. They will generally be available no later than the seventh business day after the day of your deposit.
Deposits at Automated Teller Machines
Funds from any deposits (cash or checks) made at Automated Teller Machines (ATMs) we do not own or operate will be available on the fifth business day after the day of deposit. All ATMs that we own or operate are identified as our machines.
Special Rules for New Accounts
If you are a new customer, the following special rules will apply during the first 30 days your account is open.
Funds from electronic direct deposits to your account will be available on the day we receive the deposit. Funds from deposits of cash, wire transfers, and the first $5,000 of a day’s total deposits of cashier’s, certified, teller’s, traveler’s, and federal, state and local government checks will be available on the first business day after the day of your deposit, if the deposit meets certain conditions. For example, the checks must be payable to you (and you may have to use a special deposit slip). The excess over $5,000 will be available on the ninth business day after the day of your deposit. If your deposit of these checks (other than a U.S. Treasury check) is not made in person to one of our employees, the first $5,000 will not be available until the second business day after the day of your deposit.
Funds from all other check deposits will be available on the seventh business day after the day of your deposit.
ELECTRONIC FUND TRANSFERS POLICY
Your Rights and Responsibilities
Indicated below are types of Electronic Fund Transfers we are capable of handling, some of which may apply to your account. Please read this disclosure carefully because it tells you your rights and obligations for the transactions listed.
Electronic Fund Transfers Initiated By Third Parties You may authorize a third party to initiate electronic fund transfers between your account and the third party’s account. These transfers to make or receive payment may be one-time occurrences or may recur as directed by you. These transfers may use the Automated Clearinghouse (ACH) or other payments network. Your authorization to the third party to make these transfers can occur in a number of ways. In some cases, your authorization can occur when the merchant posts a sign informing you of their policy. In all cases, the transaction will require you to provide the third party with your account number and financial institution information. This information can be found on your check as well as on a deposit or withdrawal slip. Thus, you should only provide your financial institution and account information (whether over the phone, the Internet, or via some other method) to trusted third parties whom you have authorized to initiate these electronic fund transfers. Examples of these transfers include:
• Preauthorized Credits You may make arrangements for certain direct deposits to be accepted into your checking or savings.
• Preauthorized Payments You may make arrangements to pay certain recurring bills from your checking or savings.
• Electronic Check Conversion You may provide your check to a merchant or service provider who will scan the check for the encoded financial institution and account information. The merchant or service provider will then use this information to convert the transaction in an electronic fund transfer.
• Electronic Returned Check Charge You may authorize a merchant or service provider to electronically collect a charge in the event a check is returned for insufficient funds.
ATM Card Transactions Types of transactions You may access your account(s) by ATM using your ATM Card and your
personal identification number (PIN) to:
• deposit funds to checking or savings
• withdraw cash from checking or savings
• transfer funds from checking or savings to checking or savings
• get balance information about checking or savings
• account holders can use their ATM cards to make purchase at any merchants that accept Point Of Sale (POS) transactions as part of the Interlink program
Some of these services may not be available at all terminals.
Classic Cattle Check Card ATM Transactions types of transactions You may access your account(s) by ATM using your Classic Cattle Check Card and your personal identification number (PIN) (as applicable) to:
• deposit funds to checking or savings
• withdraw cash from checking or savings
• transfer funds from checking or savings to checking or savings
• get balance information about checking or savings
Some of these services may not be available at all terminals.
Classic Cattle Check Card Point-of-Sale Transactions types of transactions You may access your checking account(s) by debit card to do transactions that participating merchants will accept, including:
• purchase goods in person, by phone, or online
• pay for services in person, by phone, or online
• get cash from a participating merchant or financial institution
Advisory Against Illegal Use You agree not to use your card(s) for illegal gambling or other illegal purposes. Display of a payment card logo by, for example, an online merchant does not necessarily mean that transactions are lawful in all jurisdictions in which the cardholder may be located.
Online Banking Types of transfers You may access your accounts by computer at www.cattlebank.com and use your Password & Access ID to:
• transfer fund from checking, savings, loans to checking, savings, loans
• make payments from checking, savings, loans to checking, savings, loans
• get balance information about checking, savings, certificate of deposit or loans
• get transaction history about checking, savings, certificate of deposit or loans
Limits and Fees Please refer to our fee disclosure for information about fees and limitations that may apply to these electronic fund transfers.
ATM Operator/Network Fees When you use an ATM not owned by us, you may be charged a fee by the ATM operator or any network used (and you may be charged a fee for a balance inquiry even if you do not complete a fund transfer).
Terminal Transfers You can get a receipt at the time you make any transfer to or from your account using one of our automated teller machines or point-of-sale terminals.
Preauthorized Credits If you have arranged to have direct deposits made to your account at least once every 60 days from the same person or company, you can call us at (402)643-3636 to find out whether or not the deposit has been made.
Periodic Statements You will get monthly account statement from us for your checking account(s). You will get a monthly statement from us for your savings account(s), unless there are no transfers in a particular month. In any case, you will get a statement at least quarterly.
Right to Stop Payment and Procedure for Doing So If you have told us in advance to make regular payments out of your account, you can stop any of these payments. Here is how:
Call or write us at the telephone number or address listed in this disclosure in time for us to receive your request three business days or more before the payment is scheduled to be made. If you call, we may also require you to put your request in writing and get it to us within 14 days after you call.
Notice of Varying Amounts If these regular payments may vary in amount, the person you are going to pay will tell you, 10 days before each payment, when it will be made and how much it will be. (You may choose instead to get this notice only when the payment would differ by more than a certain amount from the previous payment, or when the amount would fall outside certain limits that you set).
Liability for Failure to Stop Payment of Preauthorized Transfer If you order us to stop one of these payments three business days or more before the transfer is scheduled, and we do not do so, we will be liable for your losses or damages.
Financial Institution’s Liability
Liability for Failure to Make Transfers If we do not complete a transfer to or from your account on time or in the correct amount according to our agreement with you, we will be liable for your losses or damages. However, there are some exceptions. We will not be liable, for instance:
• If, through no fault of ours, you do not have enough money in your account to make the transfer.
• If you have an overdraft line and the transfer would go over the credit limit.
• If the automated teller machine where you are making the transfer does not have enough cash.
• If the terminal or system was not working properly and you knew about the breakdown when you started the transfer.
• If circumstances beyond our control (such as fire or flood) prevent the transfer, despite reasonable precautions that we have taken.
• There may be other exceptions stated in our agreement with you.
We will disclose information to third parties about your account or the transfers you make:
• where it is necessary for completing transfer; or
• in order to verify the existence and condition of your account for a third party, such as a credit bureau or merchant; or
• in order to comply with government agency or court orders; or
• if you give us written permission.
(a) Consumer Liability (1) Generally, tell us AT ONCE if you believe your card and/or code has been lost or stolen or if you believe that an electronic fund transfer has been made without your permission using information from your check. Telephoning is the best way of keeping your possible losses down. You could lose all the money in your account (plus your maximum overdraft line of credit). If you tell us within two business days, you can lose no more than $50 if someone used your card and/or code without your permission. (If you believe your card and/or code has been lost or stolen, and you tell us within two business days after you learn of the loss or theft, you can lose no more than $50 if someone used your card and/or code without your permission).
If you do NOT tell us within two business days after you learn of the loss or theft of your card and/or code, and we can prove we could have stopped someone from using your card and/or code without your permission if you had told us, you could lose as much as $500.
Also, if your statement shows transfers that you did not make, tell us at once. If you do not tell us within 60 days after the statement was mailed to you, you may not get back any money you lost after the 60 days if we can prove that we could have stopped someone from taking the money if you had told us in time.
If a good reason (such as a long trip or a hospital stay) kept you from telling us, we will extend the time period.
(2) Additional Limit on liability for VISA® Check card. Unless you have been grossly negligent or have engaged in fraud, you will not be liable for any unauthorized transactions using your lost or stolen Visa card. This additional limit on liability does not apply to ATM transactions, to transactions using your Personal Identification Number, which are not processed by VISA, or to commercial cards.
(b) Contact in Event of Unauthorized Transfer If you believe your card and/or code has been lost or stolen, call or write us at the telephone number or address listed in this disclosure. You should also call the number or write to the address listed in this disclosure if you believe a transfer has been made using the information from your check without your permission.
Error Resolution Notice
In case of errors or questions about your electronic transfers, call or write us at the telephone number or address listed in this disclosure, as soon as you can, if you think your statement or receipt is wrong or if you need more information about a transfer listed on the statement or receipt. We must hear from you no later than 60 days after we sent the FIRST statement on which the problem or error appeared.
(1) Tell us your name and account number (if any).
(2) Describe the error or the transfer you are unsure about, and explain as clearly as you can why you believe it is an error or why you need more information.
(3) Tell us the dollar amount of the suspected error.
If you tell us orally, we may require that you send us your complaint or question in writing within 10 business days.
We will determine whether an error occurred with 10 business days (five business days if the transfer involved a point-of-sale transaction and 20 business days if the transfer involved a new account) after we hear from you and will correct any error promptly. If we need more time, however, we may take up to 45 days (90 days if the transfer involved a new account, a point-of-sale transaction, or a foreign-initiated transfer) to investigate your complaint or question. If we decide to do this, we will credit your account within 10 business days (five business days if the transfer involved a point-of-sale transaction and 20 business days if the transfer involved a new account) for the amount you think is in error, so that you will have the use of the money during the time it takes us to complete our investigation. If we ask you to put your complaint or question in writing and we do not receive it within 10 business days, we may not credit your account. You account is considered a new account for the first 30 days after the first deposit is made, unless each of you already has an established account with us before the account is opened.
We will tell you the results within three business days after completing our investigation. If we decide that there was no error, we will send you a written explanation.
You may ask for copies of the documents that we used in our investigation.
If you have inquiries regarding your account, please contact us at:
The Cattle National Bank & Trust Company
104 South 5th
Seward, NE 68434
BUSINESS DAYS: Monday, Tuesday, Wednesday, Thursday, Friday
Holidays are not included.
DEPOSIT ACCOUNT TERMS AND CONDITIONS
Agreement - These terms govern the operation of this account unless varied or supplemented in writing. Unless it would be inconsistent to do so, words and phrases used in this document should be construed so that the singular includes the plural and the plural includes the singular. As used in this form, the words “we,” “our,” or “us” mean the financial institution and the words “you” or “your” mean the account holder(s). “Party” means a person who, by the terms of an account, has a present right, subject to request, to payment from the account other than as a beneficiary or agent. This account may not be transferred or assigned without our written consent.
Much of our relationship with our deposit customers is regulated by state and federal law, especially the law relating to negotiable instruments, the law regulating the methods of transferring property upon death and the rights of surviving spouses and dependents, the law pertaining to estate and other succession taxes, the law regarding electronic funds transfer, and the law regarding the availability of deposited funds. This body of law is too large and complex to be reproduced here.
The purpose of this form is to:
(1) summarize the rules applicable to the more common transactions;
(2) establish rules to govern transactions or circumstances which the law does not regulate; and
(3) establish rules for certain events or transactions which the law already regulates but permits variation by agreement.
We may permit some variations from this standard agreement, but any such variations must be agreed to in writing either on our signature card for the account or in some other written form.
Liability - You agree, for yourself (and the person or entity you represent if you sign as a representative of another) to the terms of this account and the schedule of charges that may be imposed. You authorize us to deduct these charges as accrued directly from the account balance. You also agree to pay additional reasonable charges we may impose for services you request which are not contemplated by this agreement. You also agree to be severally liable for any account deficit resulting from charges or overdrafts, whether caused by you or another authorized to withdraw from this account, and the costs we incur to collect the deficit including, to the extent permitted by law, our reasonable attorneys’ fees.
Deposits Any items, other than cash, accepted for deposit (including items drawn “on us”) will be given provisional credit only until collection is final (and actual credit for deposits of, or payable in, foreign currency will be at the exchange rate in effect on final collection in U.S. dollars). Unless otherwise disclosed, interest on non-consumer accounts will be paid only on collected funds, subject to minimum balance or other limitations, if any. We are not responsible for transactions initiated by mail or outside depository until we actually record them. All transactions received after our “daily cut-off time” on a business day we are open, or received on a day in which we are not open for business, will be treated and recorded as if initiated on the next following business day that we are open.
Withdrawals Unless otherwise clearly indicated on the account records, any one of you who signs the account agreement/signature card including authorized signers, may withdraw or transfer all or any part of the account balance at any time on forms approved by us. Each of you (until we receive written notice to the contrary) authorizes each other person signing the account agreement/signature card to endorse any item payable to you or your order for deposit to this account and any other transaction with us. We may charge against your account a check, even though payment was made before the date of the check, unless you have given us written notice of the postdating. The fact that we may honor withdrawal requests which overdraw the finally collected account balance does not obligate us to do so, unless required by law. Withdrawals will first be made from collected funds, and we may, unless prohibited by law or our written policy, refuse any withdrawal request against uncollected funds, even if our general practice is to the contrary. We reserve the right to refuse any withdrawal or transfer request which is attempted by any method not specifically permitted, which is for an amount less than any minimum withdrawal requirement, or which exceeds any frequency limitation. Even if we honor a nonconforming request, repeated abuse of the stated limitations (if any) may eventually force us to close this account. We will use the date a transaction is completed by us (as opposed to the day you initiate it) to apply the frequency limitations. On interest-bearing accounts other than time deposits, we reserve the right to require at least seven days’ written notice before any withdrawal or transfer. Withdrawals from a time deposit prior to maturity or prior to the expiration of any notice period may be restricted and may be subject to penalty. See your notice of penalties for early withdrawal.
Ach and Wire Transfers This agreement is subject to Article 4A of the Uniform Commercial Code in the state in which you have your account with us. If you originate a fund transfer for which Fedwire is used, and you identify by name and number a beneficiary financial institution, an intermediary financial institution or a beneficiary, we and every receiving or beneficiary financial institution may rely on the identifying number to make payment. We may rely on the number even if it identifies a financial institution, person or account other than the one named. You agree to be bound by automated clearinghouse association rules. These rules provide, among other things, that payments made to you or originated by you, are provisional until final settlement is made through a Federal Reserve Bank or payment is otherwise made as provided in Article 4A-403(a) of the Uniform Commercial Code. If we do not receive such payment, we are entitled to a refund from you in the amount credited to your account and the party originating such payment will not be considered to have paid the amount so credited. If we receive a credit to an account you have with us by wire or ACH, we are not required to give you any notice of the payment order or credit.
Ownership of Account You intend these rules to apply to this account depending on the form of ownership and beneficiary designation, if any. We make no representations as to the appropriateness or effect of the ownership and beneficiary designations, except as they determine to whom we pay the account funds. Single Party Account Such an account is owned by one party. Multiple Party Account Parties own the account in proportion to their net contributions unless there is clear and convincing evidence of a different intent. Corporate, Partnership, and other Organizational Accounts - We reserve the right to require the governing body of the legal entity to give us a separate authorization telling us who is authorized to act on its behalf. We will honor such an authorization until we actually receive written notice of a change from the governing body.
Rights at Death - Single Party Account - At death of party, ownership passes as part of party’s estate. Multiple Party Account with Right of Survivorship At death of party, ownership passes to surviving parties. If two or more parties survive and one is the surviving spouse of the deceased party, the amount to which the deceased party, immediately before death, was beneficially entitled by law belongs to the surviving spouse. If two or more parties survive and none is the spouse of the decedent, the amount to which the deceased party, immediately before death, was beneficially entitled by law belongs to the surviving parties in equal shares. Multiple Party Account without Right of Survivorship - At death of party, deceased party’s ownership passes as part of deceased party’s estate. Single Party Account with POD (Pay-on-Death) Designation - At death of party, ownership passes to POD beneficiaries and is not part of party'’ estate. Multiple Party Accounts with Right of Survivorship and POD (Pay-on-Death) Designation At death of last surviving party, ownership passes to POD beneficiaries and is not part of last surviving party’s estate.
Stop-Payments A stop-payment order must be given in the manner required by law and must be received in time to give us a reasonable opportunity to act on it before our stop-payment cut-off time. Our stop-payment cut-off time is one hour after the opening of the next banking day after the banking day on which we receive the item. Additional limitations on our obligation to stop-payment are provided by law. A stop-payment order must precisely identify the number, date and amount of the item, and the payee. We will honor a stop-payment request by the person who signed the particular item, and, by any other person, even though such other person did not sign the item, if such other person has an equal or greater right to withdraw from this account than the person who signed the item in question. A release of the stop-payment request may be made only by the person who initiated the stop-payment.
Amendments and Termination - We may change any term of this agreement. Rules governing changes in interest rates have been provided separately. For other changes we will give you reasonable notice in writing or by any other method permitted by law. We may also close this account at any time upon reasonable notice to you and tender of the account balance personally or by mail. Notice from us to any one of you is notice to all of you.
Statements You must examine your statement of account with “reasonable promptness.” If you discover (or reasonably should have discovered) any unauthorized payments or alterations, you must promptly notify us of the relevant facts. If you fail to do either of these duties, you will have to either share the loss with us, or bear the loss entirely yourself (depending on whether we exercised ordinary care and, if not, whether we substantially contributed to the loss). The loss could be not only with respect to items on the statement but other items forged or altered by the same wrongdoer. You agree that the time you have to examine your statement and report to us will depend on the circumstances, but that such time will not, in any circumstance, exceed a total of 30 days from when the statement is first made available to you.
You further agree that if you fail to report any unauthorized signatures, alterations, forgeries or any other errors in your account within 60 days of when we made the statement available, you cannot assert a claim against us on any items in that statement, and the loss will be entirely yours. This 60 day limitation is without regard to whether we exercised ordinary care. The limitation in this paragraph is in addition to that contained in the first paragraph of this section.
Direct Deposits If, in connection with a direct deposit plan, we deposit any amount in this account which should have been returned to the Federal Government for any reason, you authorize us to deduct the amount of our liability to the Federal Government from this account or from any other account you have with us, without prior notice and at any time, except as prohibited by law. We may also use any other legal remedy to recover the amount of our liability.
Set-Off You each agree that we may (without prior notice and when permitted by law) set off the funds in this account against any due and payable debt owed to us now or in the future, by any of your having the right of withdrawal, to the extent of such persons’ or legal entity’s right to withdraw. If the debt arises from a note, “any due and payable debt” includes the total amount of which we are entitled to demand payment under the terms of the note at the time we set off, including any balance the due date for which we properly accelerate under the note. This right of set-off does not apply to this account if: (a) it is an Individual Retirement Account or other tax-deferred retirement account, or (b) the debt is created by a consumer credit transaction under a credit card plan, or (c) the debtor’s right of withdrawal arises only in a representative capacity. We will not be liable for the dishonor of any check when the dishonor occurs because we set off a debt against this account. You agree to hold us harmless from any claim arising as a result of our exercise of our right of set-off.
Agency (Power Of Attorney) Designation Agents may make account transactions on behalf of the parties, but have no ownership or rights at death unless named as Pay-on-Death beneficiaries.
Restrictive Legends We are not required to honor any restrictive legend on checks you write unless we have agreed to the restriction in writing signed by one of our officers. Examples of restrictive legends are “must be presented within 90 days” or “not valid for more than $1,000.”
HEALTH SAVINGS ACCOUNT AGREEMENT
The account owner and custodian make the following agreement:
This agreement relates to a Health Savings Account as defined in IRS Code Section 223 as detailed in IRS Publication 969.
The Custodian will accept only cash (or check) contributions except in the case of a rollover contribution from an HSA or an Archer Medical Savings Account (Archer MSA).
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).
2. 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.
3. 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.
1. For calendar year 2012, the maximum annual contribution limit for an account owner with single coverage is $3,100. For calendar year 2012, the maximum annual contribution limit for an account owner with family coverage is $6,250. These limits are subject to cost-of-living adjustments after 2012. Your eligibility to contribute to an HSA is determined by the effective date of your HDHP coverage. If you do not have HDHP coverage for the entire year, you will not be able to make the maximum contribution. All contribtuions (including catch-up contributions) must be pro-rated. Your annual contribution depends on the number of months of HDHP coverage you have during the year (count only the months where you have HDHP coverage on the first day of the month). For years after 2006 a special rule allows you to contribute the maximum amount for the year as long as you have coverage for December. However, if you fail to remain covered for the following year, the extra contribution above the pro rated amount is included in income and subject to an additional 10 percent tax.
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) need not be in cash and are not subject to the maximum annual contribution limit set forth in Article II.
4. Contributions to Archer MSAs or other HSAs count toward the maximum annual contribution limit to this HSA.
5. 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.
6. 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.
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. The custodian may charge a fee of $35.00 for the correction and distribution of excess contributions.
The account owner’s interest in the balance in this custodial account is non-forfeitable.
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).
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 10 percent tax on that amount. The additional 10 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.
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.
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.
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.
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 above.
Additional Documents - Additional documents may be attached to this agreement and, if accepted by both parties, become part of this agreement.
Fees - We may change fees at any time by providing you with notice of such changes. Fees may be deducted directly from your HSA or billed to you separately at our discretion.
Delivery - Any notice mailed to you will be deemed delivered to and received by you two days after the postmark date.
Applicable Law - This agreement will be interpreted in accordance with the laws of the State of Nebraska.
Disqualification - Any provisions of this agreement that would disqualify this account as an HSA will be disregarded only to the extent required to qualify the account as an HSA.
Interpretation - The meaning of any provision of this agreement shall be our interpretation of its meaning and our interpretation shall be binding upon all parties to the agreement.
Representations - The account owner represents that all information provided to us is accurate and complete and that your actions comply with this agreement as well as all laws and regulations pertaining to HSAs. We will rely upon the information provided to us by you and are under no obligation to substantiate or investigate such information. By signing this agreement, you hold us harmless and indemnify us against any and all actions, losses or liabilities incurred by reason of your actions, directions, information or representations.
Professional Advice - It is the account owner’s responsibility to seek the guidance of a legal or tax professional regarding the suitability of an HSA for the account owner’s particular situation including the tax and legal consequences.
Termination - You may terminate this agreement at any time without our consent with a written notice of termination. Upon the termination, you can appoint a qualified successor custodian or trustee to whom your HSA assets will be transferred or request a distribution. These directions will be carried out as soon as administratively possible. Any resulting fees or expenses will be deducted from the transfer or distribution. By signing this agreement, you hold us harmless and indemnify us against any and all adverse consequences of the requested termination and transfer or distribution.
Resignation - We may resign as custodian at any time by providing 30 days written notice prior to such resignation. Upon our resignation, you can appoint a qualified successor custodian or trustee to whom your HSA assets will be transferred or request a distribution. These directions will be carried out as soon as administratively possible. If you fail to provide us with acceptable direction within 30 days, we may, at our discretion, transfer the assets to a successor custodian or trustee of our choice or distribute the assets to you. Any resulting fees or expenses will be deducted from the transfer or distribution. By signing this agreement, you hold us harmless and indemnify us against any and all adverse consequences of the resignation and transfer or distribution.
Successor Organization - If we merge with, purchase or are acquired by another organization, that organization will automatically become the successor custodian or your HSA.
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. For more information on HSAs, see Notice 2004-2, 2004-2 I.R.B. 269, Notice 2004-50, 2004-33 I.R.B. 196, Publication 969, and other IRS published guidance.
High Deductible Health Plan (HDHP) - For calendar year 2012, 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 $6,050. For calendar year 2012, an HDHP for family coverage has a minimum annual deductible of $2,400 and an annual out-of-pocket maximum of $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. See IRS Publication 502 for additional information. 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.
HEALTH SAVINGS ACCOUNT DISCLOSURE STATEMENT
IMPORTANT NOTE: The Cattle National Bank & Trust Co. Health Savings Account Disclosure Statement is provided as a service to persons who are considering opening a Health Savings Account (HSA). This Disclosure Statement is furnished to individuals with the understanding that qualifications for opening and maintaining an HSA are complex, the Disclosure Statement is believed to be accurate as of January 31, 2006, future changes in the law or interpretations of the law may occur that could make the information in this Disclosure Statement incorrect or incomplete, and that The Cattle National Bank & Trust Co. is under no obligation to update the information in this Disclosure Statement. Furthermore, this Disclosure Statement is furnished with the understanding that an individual considering whether to open an HSA is doing so only after having read the Disclosure Statement and, to the extent necessary, after having consulted with the individual’s own accountant or tax advisor. We are not responsible for providing tax or legal advice and this disclosure is neither. This Disclosure Statement only describes information relating to the tax treatment of HSAs under the Federal Internal Revenue Code (“Code”), and does not address any other information or laws that may apply to HSAs (including state laws or laws of any other taxing jurisdiction).
Overview and Eligibility Requirements
What is a Health Savings Account? A Health Savings Account (“HSA”) is a tax-exempt trust or custodial account created for the purpose of saving and paying for qualified medical expenses in connection with a high-deductible health plan. Authorized by Section 1201 of the Medicare Prescription Drug Improvement and Modernization Act of 2003, an HSA is established for the benefit of an individual, and is “portable.” This means that if you change employers or leave the work force, the HSA stays with you rather than with your former employer.
Who is eligible for an HSA? An “eligible individual” may establish an HSA. An “eligible individual” means, with respect to any month, an individual who (i) is covered under a high-deductible health plan as of the first day of the month, (ii) is not also covered by any other health plan that is not a high-deductible health plan (with certain exceptions for certain types of permitted coverage, as discussed more fully below), (iii) is not entitled to Medicare benefits, and (iv) may not be claimed as a dependent on another person’s tax return.
What is a “high-deductible health plan” that makes someone eligible for an HSA? A “high-deductible health plan” is a health plan that: (1) has an annual deductible of at least $1,200 for individual (self-only) coverage or (2) has an annual deductible of at least $2,400 for family (coverage of more than one individual) coverage. In addition, the annual out-of-pocket expenses required to be paid under the plan cannot exceed $6,050 for individual coverage and $12,100 for family coverage. Out-of-pocket expenses include deductibles, co-payments, and other amounts the participant must pay for covered benefits, but do not include premiums or amounts incurred for non-covered benefits (including amounts in excess of usual, customary and reasonable amounts, and financial penalties). The dollar amounts discussed above are the amounts in effect during 2011, but are subject to being increased for inflation.
Can a health plan that imposes a lifetime limit on benefits still qualify as a high-deductible health plan? A plan does not fail to be treated as a high-deductible health plan merely because it imposes a reasonable lifetime limit on benefits provided under the plan. In such a case, amounts paid above a lifetime limit will not be treated as out-of-pocket expenses in determining the annual out-of pocket maximum.
Can a health plan that does not have a deductible for preventive care still qualify as a high-deductible health plan? A plan does not fail to be treated as a high-deductible health plan merely because it does not have a deductible (or has a small deductible) for preventive care. For this purpose, preventive care includes such items as periodic health evaluations, routine prenatal and well-child care, child and adult immunizations, tobacco cessation programs, obesity weight-loss programs, and certain screening services.
Who can offer a high-deductible health plan? A high-deductible health plan may be offered by a variety of entities, including insurance companies and health maintenance organizations (HMOs).
Can you be covered by another health plan and still be eligible for an HSA? Except as provided below, you are ineligible for an HSA if you are covered under another health plan that is not a high-deductible health plan (whether as an individual, spouse or dependent) in addition to your qualified high-deductible health plan.
What other types of health coverage can you maintain without losing eligibility for an HSA? You remain eligible for an HSA if, in addition to a high-deductible health plan, you have any one or more of the following: insurance under which substantially all of the coverage relates to liabilities from workers’ compensation laws, torts, or ownership or use of property (such as automobile insurance); insurance for a specified disease or illness; insurance paying a fixed amount per day (or other period) of hospitalization; or coverage (whether through insurance or otherwise) for accidents, disability, dental care, vision care, or long-term care. You may also have coverage under an Employee Assistance Program (“EAP”), and you may have a discount card that enables you to obtain discounts for health care services or products at managed care market rates. Are HSAs allowed under a cafeteria plan? A high-deductible health plan can be provided as part of a cafeteria plan. Such a high-deductible health plan can be used in conjunction with an HSA. The HSA can be established under a cafeteria plan.
Can an employer allow you to elect an HSA mid-year if offered as a new benefit under the employer’s cafeteria plan? An employer may offer an HSA mid-year as a new benefit under a cafeteria plan, and allow you to elect an HSA, so long as your election for the HSA is made on a prospective basis. In such a situation, however, you may have other coverage under the cafeteria plan that cannot be changed (e.g., coverage under a health flexible spending account), which may prevent you from being an eligible individual with respect to the HSA.
Establishing an HSA
How do you establish an HSA? If you are eligible for an HSA (as described above), you can establish an HSA with a qualified HSA trustee or custodian. No permission or authorization from the Internal Revenue Service (“IRS”) is necessary. The trustee or custodian will furnish you a written HSA custodial or trust agreement.
Who can serve as an HSA trustee or custodian? Any insurance company or any bank (including a similar financial institution as defined in Section 408(n) of the Code) can be an HSA trustee or custodian. In addition, any other persons already approved by the IRS to be trustees or custodians of IRAs are automatically approved to be HSA trustees or custodians.
Can you revoke your HSA? For a period of seven (7) days following the date on which you enter into a Health Savings Account Custodial Agreement with The Cattle National Bank & Trust Company you have the right to revoke the Agreement. To affect a revocation, please write or call The Cattle National Bank & Trust Company, P.O. Box 467, Seward, NE 68434-0467, (402) 643-3636. In the event notice is mailed, the postmark date (or date of certification or registration, if sent by certified or registered mail) will be deemed the date of delivery, provided that normal mailing procedures are followed. If you revoke your account within the foregoing time limits, you are entitled to a return of the entire amount deposited to your account without reduction for any fees, expenses, or commissions and without any adjustment for any investment gain or loss. However, a 10% excise tax may apply to the amounts distributed in connection with the revocation if the funds are not used for payment of qualified medical expenses.
Contributions to HSAs
Who may contribute to an HSA? Any person (an eligible individual, an employer, a family member, or any other person) may make contributions to an HSA on behalf of an eligible individual.
What are the rules regarding contributions made by your employer? If your employer makes a contribution to the HSA, your employer will be subject to a “comparability test.” If your employer provides a high-deductible health plan and makes HSA contributions for some employees, then your employer is required to make available comparable contributions on behalf of all employees with comparable coverage. For this purpose, the term “comparable contributions” means contributions that are either (i) the same amount, or (ii) the same percentage of the annual deductible limit under the high-deductible plan.
In what form may contributions be made to an HSA? Contributions to an HSA must be made in cash. As custodian of your HSA, we will accept contributions by check or direct deposit. We will also accept rollovers or transfers of assets from an Archer MSA or an HSA, in accordance with the requirements of the Internal Revenue Code. The custodian will require that those rollover contributions be in the form of cash.
How much may be contributed to an HSA? The maximum amount that may be contributed to an HSA for any year is established by the IRS for each year (depending on whether you have single coverage or family coverage). The amounts established by the IRS for 2012 are $3,100 for individual coverage and $6,250 for family coverage. You should check with your legal or tax advisor to determine the limit that applies to you for the current year. The same annual contribution limit applies regardless of whether the contributions are made by an employee, an employer, or both. For 2012 you may contribute up to the maximum amount for the year as long as you have coverage for December. However, if you fail to remain covered for 2013, the extra contribution above the pro rated amount is included in income and subject to an additional 10 percnet tax. In computing the prorated contribution amount, you may count only those months during which you (or your spouse) were covered by a high-deductible health plan for the entire month. You determine your monthly limit by calculating your annual limit as if you were eligible for the entire year and then dividing by 12. The total contribution for the year can be made in one or more payments at any time up to your tax-filing deadline (without extensions.) However, if you wish to have a contribution made between January 1 and April 15 treated as a contribution for the preceding taxable year, you must provide written notification to us at the time such contribution is made. Otherwise, it will be treated as a contribution for the current taxable year. The annual limit is decreased by aggregate contributions to a medical savings account (Archer MSA).
When may “catch-up” contributions be made to an HSA? If you are age 55 or over, you can make additional “catchup” contributions to your HSA. The amount of this additional “catch-up” contribution is $1,000.
What is the tax treatment of an eligible individual’s HSA contributions? When you make an eligible contribution to an HSA, the amount of your contribution (up to the maximum contribution limit discussed above) is deductible in computing your adjusted gross income. This means that your contributions are deductible whether or not you itemize deductions. In addition, any person who may be claimed as a dependent on another taxpayer’s return may not claim a deduction for a contribution to an HSA. A special rule applies to certain married individuals. If either spouse has family coverage under a high-deductible health plan, both spouses shall be treated as having only such family coverage (and if such spouses each have family coverage under different plans, as having the family coverage with the lowest annual deductible). The amount allowable as a deduction after application of this rule shall be divided equally between the spouses unless they agree on a different division.
What is the tax treatment of employer contributions to an HSA? If your employer makes a contribution to an HSA for you, you are not allowed to deduct that contribution on your income tax return. Your employer, however, will be able to deduct the contribution up to your maximum contribution limit for that year. Although you cannot deduct your employer’s HSA contribution, the contribution is not taxable to you or subject to income tax withholding or other employment taxes if it does not exceed your maximum contribution limit for that year.
When is the deadline for contributions to an HSA for any particular year? You may make HSA contributions for a particular year no later than the deadline, without extensions, for filing your federal income tax return for that year. For calendar year taxpayers, this is generally April 15 following the year for which the contributions were made. However, we will treat any contribution made between January 1 and April 15 as a contribution for the current taxable year unless you provide written notice to us at the time of such contribution that the contribution is for the preceding taxable year.
What happens when HSA contributions exceed the amount that may be deducted or excluded from gross income? A contribution made by you or your employer to an HSA that exceeds the amount allowed by law, or which is made during any year when you are not eligible to contribute, is called an “excess contribution.” Excess contributions are not deductible by you or your employer and are included in your gross income if made on your behalf by your employer. In addition, excess contributions are subject to a 6% excise tax for each year they remain in your HSA. However, you may avoid this excise tax if the excess contribution is not deducted and if you remove the excess contribution from your HSA, together with any net income attributable to the excess contribution, before the due date for filing your federal income tax return, including extensions, for the year for which the excess contribution was made. In that case, the net income attributable to the excess contribution would be taxable as income for the year in which the distribution is made, but, the removed excess contribution would not be taxable as income to you. Rollover contributions do not count in determining whether an excess contribution has been made. The custodian may charge a fee of $35.00 for the correction and distribution of excess contributions.
Who is responsible for determining the amount of eligible contributions? You are responsible for determining your eligibility for an HSA and the amount of eligible contributions during any year. You are encouraged to speak with your tax advisor about these matters. As custodian, we have no responsibility for determining or advising you whether any contribution complies with the requirements and limitations of the Code.
Rollovers and Transfers
What are the rules regarding rollovers and transfers of HSAs? You may withdraw any portion or all of the funds from one HSA or Archer MSA and roll them to an HSA account with another custodian or trustee. However, you are required to roll the funds into a new HSA within 60 calendar days of your receipt of the funds. Another rule provides that you are only allowed to make one HSA rollover in a 12-month period. The 12-month period begins on the date you receive the distribution, not on the date you roll it to another HSA. In addition, you may transfer your Archer MSA or HSA funds directly from one HSA custodian or trustee to another without ever having direct control or custody of the funds. Rollover and transfer contributions are not deductible and do not count against the annual contribution limits discussed earlier in this Disclosure Statement.
Tax Treatment of HSAs
What is the tax treatment of earnings on amounts in an HSA? Earnings on amounts in an HSA are not taxable prior to distribution from the HSA. However, HSAs are subject to the taxes imposed by Section 511 of the Code (relating to tax on unrelated business income of charitable, etc. organizations). In addition, under certain circumstances, distributions from an HSA may have tax consequences (see the following section regarding taxation of distributions).
What are the tax consequences of a “prohibited transaction”? If you or your beneficiary engages in a “prohibited transaction” as described in Section 4975 of the Code with respect to your HSA, the HSA will lose its tax exemption and its fair market value will be added to your gross income for the year in which the prohibited transaction takes place. In addition to any regular income tax that may be payable, the 10% premature distribution penalty tax may also be applicable.
Are there any tax consequences to pledging your HSA as security for a loan? Any portion of your HSA that you pledge as security for a loan will be treated as being distributed to you in that year. In addition to any regular income tax that may be payable, the 10% premature distribution penalty tax may also be applicable.
Will your custodian provide any tax advice in connection with your HSA? As custodian, we will provide no tax advice concerning your HSA. The tax consequences of your HSA, including all contributions to and distributions from your HSA, are your sole responsibility. You are encouraged to discuss any questions with your own tax advisor.
Distributions from HSAs
When can you receive distributions from an HSA? You can take a distribution from your HSA at any time.
How are distributions from an HSA taxed? Distributions from an HSA for the qualified medical expenses of you or your spouse or dependents who are covered by the high-deductible health plan are generally excludable from income for Federal income tax purposes if such expenses are not covered by insurance. Distributions used for any other purpose are includible in income and may also be subject to an additional 10% tax (see below).
When are you subject to the 10% premature distribution penalty tax? Generally, if an HSA distribution is included in your gross income because it is not made for “qualified medical expenses,” it will also be subject to an additional 10% premature distribution penalty tax. This 10% penalty tax does not apply to distributions made after your death, disability or attainment of age 65.
What happens if you receive an HSA distribution as the result of a mistake of fact due to reasonable cause? If there is clear and convincing evidence that amounts were distributed from an HSA because of a mistake of fact due to reasonable cause, you may repay the mistaken distribution no later than April 15 following the first year you knew or should have known the distribution was a mistake. Under these circumstances, the distribution is not included in your gross income or subject to the 10% additional tax, and the repayment is not subject to the 6% excise tax for excess contributions.
What medical expenses are eligible for tax-free distributions from your HSA? Distributions made for “qualified medical expenses” are generally excludable from income. For this purpose, the term “qualified medical expenses” means amounts paid for the medical care, as defined in Section 213(d) of the Code, of yourself, your spouse, or your dependents, but only to the extent such amounts are not compensated by insurance or otherwise. This includes amounts paid for the diagnosis, cure, mitigation, treatment, or prevention of disease or for the purpose of affecting any structure or function of the body, as well as for transportation primarily for and essential to such care. Qualified medical expenses do not include insurance premiums other than premiums for long-term care insurance, premiums on a health plan during any period of continuation coverage required by Federal law (e.g., “COBRA” coverage), or premiums for health care coverage while an individual receives unemployment compensation.
Is your custodian responsible for determining whether HSA distributions are used for medical expenses? As custodian, we have no responsibility for determining whether distributions from your HSA are used for qualified medical expenses. It is your sole responsibility to determine the tax consequences of any distributions, for maintaining adequate records for tax purposes, and for paying any taxes and penalties arising as a result of any such distribution. You are encouraged to consult with your legal or tax advisor concerning any questions you may have.
If you are a retiree and age 65 or older, may you receive tax-free distributions from an HSA to pay your contribution to your employer’s retiree health coverage? After you reach age 65, you may receive tax-free distributions from an HSA to pay for your employer’s retiree health insurance coverage. Although the purchase of health insurance is generally not a qualified medical expense that can be paid or reimbursed by an HSA, the Code provides an exception for coverage for health insurance once an account beneficiary reaches age 65. This exception applies to both insured and self-insured plans.
If you are a retiree who is enrolled in Medicare, may you receive a tax-free distribution from an HSA to reimburse your Medicare premiums? Such a distribution will be tax-free. When premiums for Medicare are deducted from Social Security benefit payments, an HSA distribution to reimburse an amount equal to the Medicare premium deduction is a qualified medical expense.
Divorce or Death of HSA Account Holder
What are the rules that apply if your HSA is transferred pursuant to a divorce decree? The transfer of your HSA to your spouse pursuant to a divorce decree is not considered a taxable transfer. After such transfer, the former spouse will be treated as the account holder of the HSA, but the former spouse must request us to transfer the account to his or her name, must provide us with a certified copy of the divorce decree and property settlement or transfer agreement, and must sign appropriate documents to establish the account in that person’s name.
What happens to your HSA upon your death? You have the right at any time to designate one or more beneficiaries to whom distribution of your HSA will be made upon your death. You also have the right to revoke a prior beneficiary designation and, if desired, designate different individuals as beneficiaries. To be valid, any such beneficiary designation must be delivered to us prior to your death on a form provided by or acceptable to us. In the absence of a valid beneficiary designation, we will distribute the assets comprising your HSA upon your death to your estate. You should understand that in certain states, your spouse’s consent may be necessary if you wish to name a person other than or in addition to your spouse as beneficiary or to change an existing beneficiary designation. You should consult with your attorney before making such a beneficiary designation.
What are the tax consequences of HSA distributions following your death? If your spouse is the named beneficiary of your HSA, your HSA becomes the HSA of your spouse upon your death, subject to our consent and the completion of applicable documents as required by us. The surviving spouse is not required to include any amount in gross income for tax purposes as a result of your death and he or she is subject to income tax only on those distributions which are not made for qualified medical expenses. If, at your death, your HSA passes to a named beneficiary other than your surviving spouse, the HSA ceases to be an HSA as of the date of your death, and the beneficiary is required to include the fair market value of the HSA assets as of the date of death in his or her gross income for the taxable year that includes the date of death. The includible amount is reduced by the amount in the HSA used, within one year of your death, to pay your qualified medical expenses incurred prior to death. If there is no named beneficiary of your HSA, the HSA ceases to be an HSA as of the date of your death, and the fair market value of the HSA assets as of the date of death is includible in your gross income for the year of death.
Statements and Filing Requirements
What information must be filed with the IRS? As custodian, we will send each year to the IRS and to you a form, showing a valuation of your HSA as of December 31 of the prior year, and a report of the contributions to your HSA for the prior year. Unless we receives either a certification from your employer that contributions were made by the employer, or a notification from you that a contribution is a rollover contribution, all contributions will be reported as tax-deductible contributions made by you. Distributions will be reported by us on Form 1099-SA. Unless you provide written notice to the contrary, we will conclusively assume that any distribution, whether by check, debit card, or otherwise, is a “normal distribution” for purposes of tax reporting. Normal distributions include distributions for qualified medical expenses, and expressly exclude the following: return of excess contributions, distributions following your disability, distributions following your death, and prohibited transactions. If a distribution falls within one of these exceptions, you must provide written notification to us within seven (7) days following such distribution.
Other Legal Requirements: In addition to the legal requirements discussed elsewhere in this Disclosure Statement, your HSA is subject to the following rules:
• None of the funds of your HSA may be invested in life insurance contracts.
• With the exception of investments in a common trust fund or common investment fund, no assets of your HSA may be commingled.
• Your interest in the balance of the HSA custodial account is non-forfeitable.
Note that any HSA you establish with us. Is subject to the terms set forth in the Savings Account Custodial Agreement, the HSA Deposit Account Terms and Conditions, the Enrollment Form and the Additional Information related thereto, and the VISA® HSA Debit Card Cardholder Agreement.
LIMITS AND FEES DISCLOSURE
The following fees may be assessed against your account.
Replace ATM or VISA® Check Card / Card not returned-----$10.00
Nonsufficient funds (NSF fee) (paid or returned)-----$25.00 each
Correction of excess contribution fee-----$35.00 each
Transfer Out fee-----$35.00
Account research (Minimum one hour)-----$25.00 / hr.
Account balancing assistance (Minimum one hour)-----$25.00 / hr.
Cashier’s check-----$5.00 each
Money order-----$3.00 each
Telephone transfer from checking or savings-----$2.50
Online transfer from checking or savings-----Free
Stop payment all items-----$30.00
Wire transfer (noncustomer) (incoming or outgoing)-----$20.00
Wire transfer (customer) (outgoing only, incoming is free)-----$15.00
VISA Check Card chargeback-----$15.00
Change of address fee-----$5.00
Check collection fee-----$10.00