Hsa Durable Power Of Attorney Form (Page 2 of 2) in pdf

Hsa Durable Power Of Attorney Form Page 2

HSA DURABLE POWER OF ATTORNEY FORM

_ _ _ _ _ _ _ _ _ _

HSA Account Number

9 5 0 0

I ____________________________________________________________________

residing at __________________________________________________________________________,

owner of the BenefitWallet Health Savings Account (HSA) referenced above, do hereby appoint

____________________________________________________________ (first and last name and

relationship to account holder), residing at_____________________________________________, as

my true and lawful agent for the limited purpose of performing any act I may perform pursuant to the

agreement governing my HSA as though I performed the act myself. I agree that this Power of Attorney

shall be governed by Massachusetts law, the state where my HSA is located.

This power of attorney will not be affected by my subsequent disability or incapacity. I agree to hold any

person or entity harmless and be solely responsible for any and all damages or costs, without limitation,

such person or entity incurs due to its reliance on this Power of Attorney. Any person or entity may rely on

this Power of Attorney until that person or entity has actual knowledge of its revocation.

_______________________________________

_______________

Signature of Owner

Date

Before me, the undersigned authority, personally appeared _______________________, who being duly

sworn according to law, deposed and said that he/she is the Health Savings Account owner identified in

the foregoing power of attorney form.

______________________________________________________

Notary Public

Your account number may be found in the upper right corner of your BenefitWallet Welcome Kit cover

letter, monthly statements as well as on your BenefitWallet checks and deposit slips.

June 2013 (Version 2.0)

Hsa Durable Power Of Attorney Form Page 2