Fillable Form 5305-C - Health Savings Custodial Account (Page 2 of 2) in pdf

Form 5305-C (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 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.

required for an HSA for which a return is filed

Section references are to the Internal Revenue

Custodian. A custodian of an HSA must be a

to report unrelated business taxable income.

Code.

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

Specific Instructions

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

the custodian. The form can be completed at

maximum (deductibles, co-payments and

any time during the tax year. This account

Article XI. Article XI and any that follow it

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

must be created in the United States for the

may incorporate additional provisions that are

In 2012, the $1,200 minimum annual

exclusive benefit of the account owner.

agreed to by the account owner and

deductible remains the same and the annual

custodian. The additional provisions may

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

Do not file Form 5305-C with the IRS.

include, for example, definitions, restrictions

For calendar year 2011, an HDHP for family

Instead, keep it with your records. For more

on rollover contributions from HSAs or Archer

coverage has a minimum annual deductible of

information on HSAs, see Notice 2004-2,

MSAs (requiring a rollover not later than 60

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

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

days after receipt of a distribution and limited

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

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

to one rollover during a one-year period),

minimum annual deductible remains the same

Accounts and Other Tax-Favored Health

investment powers, voting rights, exculpatory

and the annual out-of-pocket maximum

Plans, and other IRS published guidance.

provisions, amendment and termination,

increases to $12,100. These limits are subject

removal of custodian, custodian’s fees, state

to cost-of-living adjustments after 2012.

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.

5305-C

Form

(Rev. 10-2016)

Form 5305-C - Health Savings Custodial Account Page 2

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