Fillable Form 5305-B - Health Savings Trust Account (Page 2 of 2) in pdf

Form 5305-B (Rev. 10-2016)

Page

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 trustee with information necessary for the trustee to prepare any report or return required by the IRS.

2. The trustee agrees to prepare and submit any report or return as prescribed by the IRS.

Article IX

Notwithstanding any other 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

Trustee’s signature

Date

Witness’ signature

(Use only if signature of account owner or trustee is required to be witnessed.)

What's New

persons, each spouse who is eligible to open

dependents (as defined in section 152) but

an HSA and wants to contribute to an HSA

only to the extent that such amounts are not

Additional Tax Increased. For tax years

must establish his or her own account. An

compensated for by insurance or otherwise.

beginning after December 31, 2010, the

employer identification number (EIN) is

With certain exceptions, health insurance

additional tax on distributions not used for

required for an HSA for which a return is filed

premiums are not qualified medical expenses.

qualified medical expenses increases from

to report unrelated business taxable income.

Trustee. A trustee of an HSA must be a

10% to 20%.

An EIN is also required for a common fund

bank, an insurance company, a person

created for HSAs.

General Instructions

previously approved by the IRS to be a

High Deductible Health Plan (HDHP). For

trustee of an individual retirement account

Section references are to the Internal Revenue

calendar year 2011, an HDHP for self-only

(IRA) or Archer MSA, or any other person

Code.

coverage has a minimum annual deductible of

approved by the IRS.

$1,200 and an annual out-of-pocket

Purpose of Form

Specific Instructions

maximum (deductibles, co-payments and

Form 5305-B is a model trust account

other amounts, but not premiums) of $5,950.

Article XI. Article XI and any that follow it may

agreement that has been approved by the

In 2012, the $1,200 minimum annual

incorporate additional provisions that are

IRS. An HSA is established after the form is

deductible remains the same and the annual

agreed to by the account owner and trustee.

fully executed by both the account owner and

out-of-pocket maximum increases to $6,050.

The additional provisions may include, for

the trustee. The form can be completed at any

For calendar year 2011, an HDHP for family

example, definitions, restrictions on rollover

time during the tax year. This account must

coverage has a minimum annual deductible

contributions from HSAs or Archer MSAs

be created in the United States for the

of $2,400 and an annual out-of-pocket

(requiring a rollover not later than 60 days

exclusive benefit of the account owner.

maximum of $11,900. In 2012, the $2,400

after receipt of a distribution and limited to

minimum annual deductible remains the same

Do not file Form 5305-B with the IRS.

one rollover during a one-year period),

Instead, keep it with your records. For more

and the annual out-of-pocket maximum

investment powers, voting rights, exculpatory

increases to $12,100. These limits are subject

information on HSAs, see Notice 2004-2,

provisions, amendment and termination,

2004-2 I.R.B. 269, Notice 2004-50, 2004-33

to cost-of-living adjustments after 2012.

removal of trustee, trustee’s fees, state law

I.R.B. 196, Pub. 969, Health Savings

Self-only coverage and family coverage

requirements, treatment of excess

Accounts and Other Tax-Favored Health

under an HDHP. Family coverage means

contributions, distribution procedures

Plans, and other IRS published guidance.

coverage that is not self-only coverage.

(including frequency or minimum dollar

amount), use of debit, credit, or stored-value

Definitions

Qualified medical expenses. Qualified

cards, return of mistaken distributions, and

medical expenses are amounts paid for

Identifying Number. The account owner’s

descriptions of prohibited transactions. Attach

medical care as defined in section 213(d) for

social security number will serve as the

additional pages if necessary.

the account owner, his or her spouse, or

identification number of this HSA. For married

5305-B

Form

(Rev. 10-2016)

Form 5305-B - Health Savings Trust Account Page 2

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