Review the disclosures in this document. Indicate if you would like to receive a MasterCard® Debit Card, an initial order of checks and a monthly paper statement. Carefully review the tax withholding information. Please print the required information and sign the form. If you are subject to backup withholding from the IRS please make sure you strike out the words for point (2).
The Account Owner name in this Application and Adoption Agreement (Customer) and First American Bank (Custodian) hereby agree to establish a Health Savings Custodial Account ("HSA") under the provisions of the Internal Revenue Code Section 223, other relevant sections, and any additional guidance from the Internal Revenue Service. Customer hereby acknowledges receipt, understanding, and agreement with the terms governing this HSA as described in the Internal Revenue Service Publication 5305-C (the "Custodial Agreement") The Health Savings Account Disclosure Statement (the "HSA Disclosure"), and First American Bank's Rules and Regulations governing its Deposit Accounts (the "Account Rules and Regulations"). I hereby request that the following options apply to my account:
An e-statement may be provided, free of charge, if you provide us with your e-mail address.
The Internal Revenue Service does not require your consent to any provision of this document other than the certifications required to avoid back-up withholding.
Tax withholding certification: Under penalty of perjury, I certify: (1) that the tax identification number entered on this form is my correct taxpayer identification number; and (2) that I am not subject to back-up withholding because either: (a) I have not been notified that I am subject to back-up withholding as a result of a failure to report all interest or dividends; (b) the Internal Revenue Service has notified me that I am no longer subject to back-up withholding; or (c) I am an exempt recipient under Internal Revenue Service regulations. Strike part (2) of this paragraph if you have been notified that you are subject to back-up withholding due to under reporting and you have not received a notice from the Internal Revenue Service that back-up withholding has been terminated.