4

TLS, have you I.R.S. SPECIFICATIONS TO BE REMOVED BEFORE PRINTING

transmitted all R Action Date Signature
text files for this INSTRUCTIONS TO PRINTERS
cycle update? FORM 5305-B, PAGE 1 OF 2
MARGINS: TOP 1⁄2 ", CENTER SIDES. PRINTS: HEAD TO HEAD O.K. to print
PAPER: WHITE WRITING, SUB. 20. INK: BLACK
FLAT SIZE: 8" X 11"
Date PERFORATE: NONE Revised proofs
DO NOT PRINT — DO NOT PRINT — DO NOT PRINT — DO NOT PRINT requested

Form 5305-B Health Savings Trust Account Do not file

(August 2004) 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 (grantor) Date of birth of account owner Identifying number (see instructions)

Address of account owner (Street address, city, state, zip code)

Name of trustee Address or principal place of business of trustee

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 trust account.

The account owner and the trustee make the following agreement:

Article I
1. The trustee 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 trustee 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.

Article II
1. For calendar year 2004, the maximum annual contribution limit for an account owner with single coverage is the lesser of the amount of the
deductible under the HDHP but not more than $2,600. For calendar year 2004, the maximum annual contribution limit for an account owner
with family coverage is the lesser of the amount of the deductible under the HDHP but not more than $5,150. These limits are subject to
cost-of-living adjustments after 2004. Eligibility and contribution limits are determined on a month-to-month basis.
2. Contributions to Archer MSAs or other HSAs count toward the maximum annual contribution limit to this HSA.
3. For calendar year 2004, an additional $500 catch-up contribution may be made for an account owner who is at least age 55 or older and not
enrolled in Medicare. The catch-up contribution increases to $600 in 2005, $700 in 2006, $800 in 2007, $900 in 2008, and $1,000 in 2009
and later years.
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 trustee
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 trust account is nonforfeitable.

Article V
1. No part of the trust 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 trustee 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 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 trustee 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. 38260U Form 5305-B (8-2004)

 4
I.R.S. SPECIFICATIONS TO BE REMOVED BEFORE PRINTING
INSTRUCTIONS TO PRINTERS
FORM 5305-B, PAGE 2 OF 2
MARGINS: TOP 1⁄2 ", CENTER SIDES. PRINTS: HEAD TO HEAD
PAPER: WHITE WRITING, SUB. 20. INK: BLACK
FLAT SIZE: 8" X 11"
PERFORATE: NONE
DO NOT PRINT — DO NOT PRINT — DO NOT PRINT — DO NOT PRINT

Form 5305-B (8-2004) 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 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.)

General Instructions filed to report unrelated business taxable

income. An EIN is also required for a
Trustee. A trustee of an HSA must be a
bank, an insurance company, a person
Section references are to the Internal Revenue common fund created for HSAs. previously approved by the IRS to be a
Code. trustee of an individual retirement account
High Deductible Health Plan (HDHP). For
(IRA) or Archer MSA, or any other person
Purpose of Form calendar year 2004, an HDHP for self-only
approved by the IRS.
coverage has a minimum annual deductible of
Form 5305-B is a model trust account $1,000 and an annual out-of-pocket
agreement that has been approved by the maximum (deductibles, co-payments and Specific Instructions
IRS. An HSA is established after the form is other amounts, but not premiums) of $5,000.
fully executed by both the account owner and Article XI. Article XI and any that follow it
For calendar year 2004, an HDHP for family may incorporate additional provisions that are
the trustee. The form can be completed at coverage has a minimum annual deductible of
any time during the tax year. This account agreed to by the account owner and trustee.
$2,000 and an annual out-of-pocket The additional provisions may include, for
must be created in the United States for the maximum of $10,000. These limits are subject
exclusive benefit of the account owner. example, definitions, restrictions on rollover
to cost-of-living adjustments after 2004. contributions from HSAs or Archer MSAs
Do not file Form 5305-B with the IRS. Self-only coverage and family coverage (requiring a rollover not later than 60 days
Instead, keep it with your records. For more under an HDHP. Family coverage means after receipt of a distribution and limited to
information on HSAs, see Notice 2004-2, coverage that is not self-only coverage. one rollover during a one-year period),
2004-2 I.R.B. 269, Notice 2004-50, 2004-33 investment powers, voting rights, exculpatory
I.R.B. 196, Publication 969, and other IRS Qualified medical expenses. Qualified provisions, amendment and termination,
published guidance. medical expenses are amounts paid for removal of trustee, trustee’s fees, state law
medical care as defined in section 213(d) for requirements, treatment of excess
Definitions the account owner, his or her spouse, or contributions, distribution procedures
dependents (as defined in section 152) but (including frequency or minimum dollar
Identifying Number. The account owner’s only to the extent that such amounts are not
social security number will serve as the amount), use of debit, credit, or stored-value
compensated for by insurance or otherwise. cards, return of mistaken distributions, and
identification number of this HSA. For married With certain exceptions, health insurance
persons, each spouse who is eligible to open descriptions of prohibited transactions. Attach
premiums are not qualified medical expenses. additional pages if necessary.
an HSA and wants to contribute to an HSA See Notice 2004-25, 2004-15 I.R.B. 727 for
must establish his or her own account. An transition relief for distributions for qualified
employer identification number (EIN) is medical expenses incurred in calendar year
required for an HSA for which a return is 2004.

Printed on recycled paper Form 5305-B (8-2004)