TRUTH IN SAVINGS DISCLOSURE

Transcription

1 Page 1 of St. Chares Ave., New Oreans, LA TRUTH IN SAVINGS DISCLOSURE Account Type: Account #: Date: This discosure contains the rues which govern your deposit account. Uness it woud be inconsistent to do so, words and phrases used in this discosure shoud be construed so that the singuar incudes the pura and the pura incudes the singuar. Minimum Baance Requirements A minimum deposit of $20 is required to open account Service Charges A Monthy Service Cyce Charge wi be imposed if: Average month to date baance of $5,000 OR Average month to date baance of $25,000 or greater in quaifying deposits (See Additiona Terms for quaifying accounts) Monthy Service Charge amount wi be based on number of group participants. See Additiona Terms on Page 2. Additiona Fees A $15 set up fee is required at account opening. A $5.00 monthy Dormant fee wi be assessed if your account reaches Dormant account status. Variabe Rate Heath Savings Checking Account Monthy Paper Statement fee of $4.85. Monthy paper statement fee waived if one of the foowing is met: Average month to date baance of $5,000 or greater OR Average month to date baance of $25,000 or greater in quaifying deposits (See Additiona Terms for quaifying accounts) OR Account is set up for estatements If the primary account hoder decides to cance their estatement at any time or we have reason to beieve that they are not receiving their estatement or enotification, a $4.85 monthy paper statement fee wi be assessed uness the average month to date baance of $5,000 or greater OR average month to date baance of $25,000 or greater in quaifying deposits appies. The primary account hoder must maintain an active internet banking account and current, active emai address. (See Guf Coast Bank and Trust Co. Internet Banking and esign Discosure) See Notice of Discosure for Services and Fees for a ist of additiona fees that may appy. The interest rate and annua percentage yied for your account depend upon the number of participants for Group HSAs. Non-Group Participants wi be paid based on 1 to 10 Participants rate. The interest rate and annua percentage yied for these categories may change. The inita interest rate and annua percentage yied for your account is determined by the Account Interest Rate Category that you fa into. Account Interest Rate Categories Number of Participants Interest Rate Annua Percentage Yied (APY) Standard: 1-10 Participants 0.50% 0.50% Preferred: Participants 0.55% 0.55% Eite: 51 + Participants 0.60% 0.60% The interest rate and annua percentage yied stated above are accurate as of the date printed above. If you woud ike more current rate and yied information pease ca us at one of the numbers isted above. Fees may reduce earnings. HSATIS-1 Rev 7/17

2 Page 2 of 2 Frequency of Rate Change At our discretion, we may change the interest rate on your account at any time. Accrua of Interest on Noncash Deposits Interest wi begin to accrue the next business day foowing the day of your opening deposit. Compounding, Crediting and Baance Computation Interest is compounded monthy. Interest wi be credited at the end of each statement cyce. There is no minimum baance required to earn interest. If you cose your account before interest is credited, you wi not receive the accrued interest. We use the daiy baance method to cacuate the interest on your account. This method appies a daiy periodic rate to the principa in the account each day. The daiy periodic rate may vary. The period we use is days in statement cyce. Additiona Terms If the account hoder has enroed in estatements, they wi receive an emai notification when their statement is ready for viewing at (see Guf Coast Bank & Trust Co. Internet Banking and esign Discosure). Images of processed items are avaiabe onine. Active internet banking account and emai address is required at a times. If the account hoder is not activey enroed in estatements at any time, for any reason, they wi receive a monthy paper statement maied to their address of record. (See Additiona Fees on Page 1)* Your account wi be paced in Dormant Status after 12 months of Inactivity. Once an account reaches Dormant account status, you wi no onger receive periodic statements and/or estatement notifications. Images of paid checks and deposit sips are avaiabe through our onine banking website or at your oca branch. Check printing fees may appy - Prices wi vary. Checks and debit card shoud be used for Norma Distributions ony. Withdrawa forms must be submitted for other types of distributions, such as death, disabiity, prohibited, and excess contribution remova. Monthy Service Charge for empoyees of groups with a number of participants from 1-10 is $2.00, groups with a number of participants from is $1.50. Monthy Service Charge is waived for empoyees of groups with 51 + participants as ong as they are empoyed with the company that contributes to the HSA. Additona discosures for this account are incuded in your Heath Savings Agreement. Quaifying deposits incudes a persona or business checking, savings or certificates of deposits that are directy inked to this account. HSATIS-2 Rev 7/17

3 Heath Savings Account..... Custodia Booket (incudes sef-direction)

4 HEALTH SAVINGS CUSTODIAL ACCOUNT (Under section 223(a) of the Interna Revenue Code) Form5305-C (December 2011) Department of the Treasury Interna Revenue Service The account owner and the custodian make the foowing agreement: Artice I. 1. The custodian wi accept additiona cash contributions for the tax year made by the account owner or on behaf of the account owner (by an empoyer, famiy member or any other person). No contributions wi be accepted by the custodian for any account owner that exceeds the maximum amount for famiy coverage pus the catch-up contribution. 2. Contributions for any tax year may be made at any time before the deadine for fiing the account owner' s federa income tax return for that year (without extensions). 3. Roover contributions from an HSA or an Archer Medica Savings Account (Archer MSA) (uness prohibited under this agreement) need not be in cash and are not subject to the maximum annua contribution imit set forth in Artice II. 4. Quaified HSA distributions from a heath fexibe spending arrangement or heath reimbursement arrangement must be competed in a trustee-to-trustee transfer and are not subject to the maximum annua contribution imit set forth in Artice II. 5. Quaified HSA funding distributions from an individua retirement account must be competed in a trustee-to-trustee transfer and are subject to the maximum annua contribution imit set forth in Artice II. Artice II. 1. For caendar year 2011, the maximum annua contribution imit for an account owner with singe coverage is $3,050. This amount increases to $3, 100 in For caendar year 2011, the maximum annua contribution imit for an account owner with famiy coverage is $6,150. This amount increases to $6, 250 in These imits are subject to cost-of-iving adjustments after Contributions to Archer MSAs or other HSAs count toward the maximum annua contribution imit to this HSA. 3. For caendar year 2009 and ater years, an additiona $1, 000 catch-up contribution may be made for an account owner who is at east age 55 or oder and not enroed in Medicare. 4. Contributions in excess of the maximum annua contribution imit are subject to an excise tax. However, the catch-up contributions are not subject to an excise tax. Artice III. It is the responsibiity of the account owner to determine whether contributions to this HSA have exceeded the maximum annua contribution imit described in Artice II. If contributions to this HSA exceed the maximum annua contribution imit, the account owner sha notify the custodian that there exist excess contributions to the HSA. It is the responsibiity of the account owner to request the withdrawa of the excess contribution and any net income attributabe to such excess contribution. Artice IV. The account owner' s interest in the baance in this custodia account is nonforfeitabe. Artice V. 1. No part of the custodia funds in this account may be invested in ife insurance contracts or in coectibes as defined in section 408(m). 2. The assets of this account may not be comminged with other property except in a common trust fund or common investment fund. Do not fie with Interna Revenue Service Amendment 3. Neither the account owner nor the custodian wi engage in any prohibited transaction with respect to this account (such as borrowing or pedging the account or engaging in any other prohibited transaction as defined in section 4975). Artice 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 excusivey to pay or reimburse quaified medica expenses of the account owner, his or her spouse, or dependents are tax-free. However, distributions that are not used for quaified medica expenses are incuded in the account owner' s gross income and are subject to an additiona 20 percent tax on that amount. The additiona 20 percent tax does not appy if the distribution is made after the account owner' s death, disabiity, or reaching age The custodian is not required to determine whether the distribution is for the payment or reimbursement of quaified medica expenses. Ony the account owner is responsibe for substantiating that the distribution is for quaified medica expenses and must maintain records sufficient to show, if required, that the distribution is tax-free. Artice VII. If the account owner dies before the entire interest in the account is distributed, the entire account wi be disposed of as foows: 1. If the beneficiary is the account owner' s spouse, the HSA wi become the spouse' s HSA as of the date of death. 2. If the beneficiary is not the account owner' s spouse, the HSA wi cease to be an HSA as of the date of death. If the beneficiary is the account owner' s estate, the fair market vaue of the account as of the date of death is taxabe on the account owner' s fina return. For other beneficiaries, the fair market vaue of the account is taxabe to that person in the tax year that incudes such date. Artice 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. Artice IX. Notwithstanding any other artice that may be added or incorporated in this agreement, the provisions of Artices I through VIII and this sentence are controing. Any additiona artice in this agreement that is inconsistent with section 223 or IRS pubished guidance wi be void. Artice X. This agreement wi be amended from time to time to compy with the provisions of the Code or IRS pubished guidance. Other amendments may be made with the consent of the persons whose signatures appear on the Appication that accompanies this Agreement. Artice XI Your HSA Documents. This Agreement for an HSA, and any amendments or additiona provisions to such agreement, set forth the terms and conditions governing the account owner' s HSA reationship with us. This Agreement wi be accompanied by a discosure statement, which sets forth various HSA rues in simper anguage, and may aso be accompanied by other documents such as an appication or beneficiary designation. Heath Savings Account Booket-Custodia HSA-BK-C-LAZ 8/1/2014 Bankers Systems* VMP, Woters Kuwer Financia Services Page 1 of 8

5 11.02 Definitions. This Agreement refers to you as the account owner, and us as the custodian. References to "you," "your," and "HSA owner" wi mean the account owner, and "we," "us," and "our" wi mean the custodian. Upon your death, your spouse beneficiary, if appicabe, becomes "you" for purposes of this Agreement. In the event you appoint a third party, or have a third party appointed on your behaf to hande certain transactions affecting your HSA, such third party wi be considered your agent and, therefore, "you" for purposes of this Agreement. Additionay, references to "HSA" wi mean the custodia account Additiona Provisions. Additiona provisions may be attached to, and made a part of, this Agreement by either party. The provisions must be in writing, agreed to by us, and in a format acceptabe to us Our Fees and Expenses. We may charge reasonabe fees and are entited to reimbursement for any expenses we incur in estabishing and maintaining your HSA. We may change the fees at any time by providing you with notice of such changes. We wi provide you with fee discosures and poicies. Fees may be paid directy from your HSA assets, and/or bied separatey to you. The payment of fees has no effect on your contributions. Additionay, we have the right to iquidate your HSA assets to pay such fees and expenses. If you do not direct us on the iquidation, we wi iquidate the assets of our choice and wi not be responsibe for any osses or caims that may arise out of the iquidation Amendments. We may amend your HSA in any respect and at any time, incuding retroactivey, to compy with appicabe aws governing HSAs and the corresponding reguations. Any other amendments sha require your consent, by action or no action, and wi be preceded by written notice to you. Uness otherwise required, you are deemed to automaticay consent to an amendment, which means that your written approva is not required for the amendment to appy to the HSA. In certain instances the governing aw or our poicies may require us to secure your written consent before an amendment can be appied to the HSA. If you want to withhod your consent to an amendment, you must provide us with a written objection within 30 days of the receipt date of the amendment Notice and Deivery. Any notice maied to you wi be deemed deivered and received by you, five days after the postmark date. This fifth day foowing the postmark is the receipt date. Notices wi be maied to the ast address we have in our records. You are responsibe for ensuring that we have your proper maiing address. Upon your consent, we may provide you with notice in a deivery format other than by mai. Such formats may incude various eectronic deiveries. Any notice, incuding terminations, change in persona information, or contributions maied to us wi be deemed deivered when actuay received by us based on our ordinary business practices. A notices must be in writing uness our poicies and procedures provide for ora notices Appicabe Laws. This Agreement wi be construed and interpreted in accordance with the aws of, and venued in, our state of domicie Disquaifying Provisions. Any provision of this Agreement that woud disquaify the HSA wi be disregarded to the extent necessary to maintain the account as an HSA Interpretation. Ifanyquestionarisesastothemeaningof any provision of this Agreement, then we sha be authorized to interpret any such provision, and our interpretation wi be binding upon a parties Representations and Indemnity. You represent that any information you and/or your agents provide to us is accurate and compete, and that your actions compy with this Agreement and appicabe aws governing HSAs. You understand that we wi rey on the information provided by you, and that we have no duty to inquire about or investigate such information. We are not responsibe for any osses or expenses that may resut from your information, direction, or actions, incuding your faiure to act. You agree to hod us harmess, to indemnify, and to defend us against any and a actions or caims arising from, and iabiities and osses incurred by reason of your information, direction, or actions. Additionay, you represent that it is your responsibiity to seek the guidance of a tax or ega professiona for your HSA issues. We are not responsibe for determining whether any contributions or distributions compy with this Agreement and/or the federa aws governing HSAs. We are not responsibe for any taxes, judgments, penaties or expenses incurred in connection with your HSA, or any osses that are a resut of events beyond our contro. We have no responsibiity to process transactions unti after we have received appropriate direction and documentation, and we have had a reasonabe opportunity to process the transactions. We are not responsibe for interpreting or directing beneficiary designations or divisions Investment of HSA Assets. (a) Investment of Contributions. We wi invest HSA contributions and reinvest your HSA assets as directed by you based on our then-current investment poicies and procedures. If you fai to provide us with investment direction for a contribution, we wi return or hod a or part of such contribution based on our poicies and procedures. We wi not be responsibe for any oss of HSA income associated with your faiure to provide appropriate investment direction. (b) Directing Investments. A investment directions must be in a format or manner acceptabe to us. You may invest in any HSA investments that you are quaified to purchase, and that we are authorized to offer and do offer at the time of the investment seection, and that are acceptabe under the appicabe aws governing HSAs. Your HSA investments wi generay be registered in our name or our nominee' s name (if appicabe) for the benefit of your HSA. Specific investment information may be provided at the time of the investment. Based on our poicies, we may aow you to deegate the investment responsibiity of your HSA to an agent by providing us with written notice of deegation in a format acceptabe to us. We wi not review or guide your agent' s decisions, and you are responsibe for the agent' s actions or faiure to act. We are not responsibe for directing your investments, or providing investment advice, incuding guidance on the suitabiity or potentia market vaue of various investments. For investments in securities, we wi exercise voting rights and other simiar rights ony at your direction, and according to our then-current poicies and procedures. Heath Savings Account Booket-Custodia Bankers Systems* VMP, Woters Kuwer Financia Services HSA-BK-C-LAZ 8/1/2014 Page 2 of 8

6 (c) Investment Fees and Asset Liquidation. Certain investment-reated fees, which appy to your HSA, must be charged to your HSA and cannot be paid by you. We have the right to iquidate your HSA assets to pay fees and expenses, federa tax evies, or other assessments on your HSA. If you do not direct us on the iquidation, we wi iquidate the assets of our choice and wi not be responsibe for any osses or caims that may arise out of the iquidation. (d) Deposit Investments. The deposit investments provided by us may incude savings, share, and/or money market accounts, and certificates of deposit (CDs). (e) Non-Deposit Investments. Non-deposit investments incude investments in property, annuities, mutua funds, stocks, bonds, and government, municipa and U.S. Treasury securities, and other simiar investments. Most, if not a, of the investments we offer are subject to investment risks, incuding possibe oss of the principa amount invested. Specific investment discosures may be provided to you Distributions. Withdrawa requests must be in a format acceptabe to us, and/or on forms provided by us. We may require you, or your beneficiary after your death, to provide documentation and a proper tax identification number before we process a distribution. These withdrawas may be subject to taxes, withhoding, and penaties. Distributions wi generay be in cash or in kind based on our poicies. In-kind distributions wi be vaued according to our poicies at the time of the distribution. Any distribution by check, debit card or other method approved by us wi be reported as a norma distribution, uness we inform you otherwise or uness - at the time of the distribution - we provide you with a means to state otherwise and you in fact state otherwise. Our poicies may permit us to accept the return of a mistaken distribution Cash or In-Kind Contributions. We may accept transfers, roovers, and other simiar contributions, remotey or in person, in cash or in kind from other HSAs and from Archer Medica Savings Accounts (MSAs). Prior to competing such transactions we may require that you provide certain information in a format acceptabe to us. In-kind contributions wi be vaued according to our poicies and procedures at the time of the contribution Reports and Records. We wi maintain the records necessary for IRS reporting on this HSA. Required reports wi be provided to you, or your beneficiary after your death, and the IRS. If you beieve that your report is inaccurate or incompete you must notify us in writing within 30 days foowing the receipt date. Your investments may require additiona state and federa reporting Termination. You may terminate this Agreement without our consent by providing us with a written notice of termination. A termination and the resuting distribution or transfer wi be processed and competed as soon as administrativey feasibe foowing the receipt of proper notice. At the time of termination we may retain the sum necessary to cover any fees and expenses, taxes, or investment penaties Our Resignation. We can resign at any time by providing you with 30 days written notice prior to the resignation date, or within five days of our receipt of your written objection to an amendment. In the event you materiay breach this Agreement, we can terminate this Agreement by providing you with five days prior written notice. Upon our resignation, you must appoint a quaified successor custodian or trustee. Your HSA assets wi be transferred to the successor custodian or trustee once we have received appropriate direction. Transfers wi be competed within a reasonabe time foowing our resignation notice and the payment of your remaining HSA fees or expenses. We reserve the right to retain HSA assets to pay any remaining fees or expenses. At the time of resignation we may retain the sum necessary to cover any fees and expenses, taxes, or investment penaties. If you fai to provide us with acceptabe transfer direction within 30 days from the date of the notice, we can transfer the assets to a successor custodian or trustee of our choice, distribute the assets to you in kind, or iquidate the assets and distribute them to you in cash Successor Organization. If we merge with, purchase, or are acquired by, another organization, such organization, if quaified, may automaticay become the successor custodian or trustee of your HSA Tax Year of Contributions. Any transaction, incuding a remote transaction - such as a computer/internet, ATM, or night deposit transaction - that resuts in a reguar contribution to the HSA is considered a current tax year contribution. However, we may aow you to specify the tax year for a reguar contribution at the time of the contribution. Heath Savings Account Booket-Custodia Bankers Systems* VMP, Woters Kuwer Financia Services HSA-BK-C-LAZ 8/1/2014 Page 3 of 8

7 IRS FORM 5305-C INSTRUCTIONS ( ) What's New Additiona Tax Increased. For tax years beginning after December 31, 2010, the additiona tax on distributions not used for quaified medica expenses increases from 10% to 20%. Genera Instructions Section references are to the Interna Revenue Code. Purpose of Form Form 5305-C is a mode custodia account agreement that has been approved by the IRS. An HSA is estabished after the form is fuy executed by both the account owner and the custodian. The form can be competed at any time during the tax year. This account must be created in the United States for the excusive benefit of the account owner. Do not fie Form 5305-C with the IRS. Instead, keep it with your records. For more information on HSAs, see Notice , I.R.B. 269, Notice , I.R.B. 196, Pub. 969, Heath Savings Accounts and Other Tax-Favored Heath Pans, and other IRS pubished guidance. Definitions Identifying Number. The account owner' s socia security number wi serve as the identification number of this HSA. For married persons, each spouse who is eigibe to open an HSA and wants to contribute to an HSA must estabish his or her own account. An empoyer identification number (EIN) is required for an HSA for which a return is fied to report unreated business taxabe income. An EIN is aso required for a common fund created for HSAs. High Deductibe Heath Pan (HDHP). For caendar year 2011, an HDHP for sef-ony coverage has a minimum annua deductibe of $1, 200 and an annua out-of-pocket maximum (deductibes, co-payments and other amounts, but not premiums) of $5, 950. In 2012, the $1,200 minimum annua deductibe remains the same and the annua out-of-pocket maximum increases to $6, 050. For caendar year 2011, an HDHP for famiy coverage has a minimum annua deductibe of $2, 400 and an annua out-of-pocket maximum of $11,900. In 2012, the $2,400 minimum annua deductibe remains the same and the annua out-of-pocket maximum increases to $12,100. These imits are subject to cost-of-iving adjustments after Sef-ony coverage and famiy coverage under an HDHP. Famiy coverage means coverage that is not sef-ony coverage. Quaified medica expenses. Quaified medica expenses are amounts paid for medica care as defined in section 213(d) for the account owner, his or her spouse, or dependents (as defined in section 152) but ony to the extent that such amounts are not compensated for by insurance or otherwise. With certain exceptions, heath insurance premiums are not quaified medica expenses. Custodian. A custodian of an HSA must be a bank, an insurance company, a person previousy approved by the IRS to be a custodian of an individua retirement account (IRA) or Archer MSA, or any other person approved by the IRS. Specific Instructions Artice XI. Artice XI and any that foow it may incorporate additiona provisions that are agreed to by the account owner and custodian. The additiona provisions may incude, for exampe, definitions, restrictions on roover contributions from HSAs or Archer MSAs (requiring a roover not ater than 60 days after receipt of a distribution and imited to one roover during a one-year period), investment powers, voting rights, excupatory provisions, amendment and termination, remova of custodian, custodian' s fees, state aw requirements, treatment of excess contributions, distribution procedures (incuding frequency or minimum doar amount), use of debit, credit, or stored-vaue cards, return of mistaken distributions, and descriptions of prohibited transactions. Attach additiona pages if necessary. Heath Savings Account Booket-Custodia Bankers Systems* VMP, Woters Kuwer Financia Services HSA-BK-C-LAZ 8/1/2014 Page 4 of 8

8 HEALTH SAVINGS ACCOUNT DISCLOSURE STATEMENT This Discosure Statement. This Discosure Statement provides you, or your beneficiaries after your death, with a summary of the rues and reguations governing this HSA. Definitions. The Heath Savings Custodia Account agreement contains a definitions section. The definitions found in such section appy to this Agreement. It refers to you as the account owner, and us as the custodian. References to "you," "your," and "HSA owner" wi mean the account owner, and "we," "us," and "our" wi mean the custodian. Upon your death, your spouse beneficiary, if appicabe, becomes "you" for purposes of this Discosure Statement. In the event you appoint a third party, or have a third party appointed on your behaf to hande certain transactions affecting your HSA, such third party wi be considered your agent and, therefore, "you" for purposes of this Discosure Statement. Additionay, references to "HSA" wi mean the custodia account. For Additiona Guidance. It is in your best interest to seek the guidance of a tax or ega professiona before competing any HSA estabishment documents. Your first reference for questions concerning your HSA shoud be Interna Revenue Code (IRC) Section 223, other reevant IRC sections, and a additiona Interna Revenue Service (IRS) guidance; IRS pubications that incude information about HSAs; any additiona provisions or amendments to such documents; and this Discosure Statement. For more information, you can aso refer to the instructions to your federa income tax return, your oca IRS office, or the IRS' s web site at www. irs. gov. HSA Restrictions and Approva. 1. Heath Savings Custodia Account Agreement. This Discosure Statement and the Heath Savings Custodia Account agreement, amendments, appication, and additiona provisions set forth the terms and conditions governing your HSA. Such documents are the "Agreement." 2. Individua/Famiy Benefit. This HSA must be for the excusive benefit of you, your spouse, and your dependents and, upon your death, your beneficiaries. The HSA must be estabished in your name and not in the name of your beneficiary, iving trust, or another party or entity. 3. Beneficiary Designation. By competing the appropriate section on the corresponding Heath Savings Account Appication you may designate any person(s) as your beneficiary to receive your HSA assets upon your death. You may aso change or revoke an existing designation in such manner and in accordance with such rues as we prescribe for this purpose. If there is no beneficiary designation on fie at the time of your death, or if none of the beneficiaries on fie are aive at the time of your death, your HSA assets wi be paid to your estate. We may rey on the atest beneficiary designation on fie at the time of your death, wi be fuy protected in doing so, and wi have no iabiity whatsoever to any person making a caim to the HSA assets under a subsequenty fied designation or for any other reason. 4. Cash Contributions. Reguar or annua HSA contributions must be in cash, which may incude a check, money order, or wire transfer. It is within our discretion to accept in-kind contributions for roovers, transfers, or simiar transactions. 5. HSA Custodian. An HSA custodian must be a bank, an insurance company, a person previousy approved by the IRS to be a trustee of an individua retirement account (IRA) or Archer Medica Savings Account (MSA) or any other person approved by the IRS. 6. Prohibition Against Life Insurance and Comminging. None of your HSA assets may be invested in ife insurance contracts, or comminged with other property, except in a common trust fund or common investment fund. 7. Nonforfeitabiity. The assets in your HSA are not forfeitabe. 8. Cash or In-Kind Roovers. You may be eigibe to make a roover contribution of your HSA or Archer MSA distribution, in cash or in kind, to an HSA. These and other potentia roovers to and from HSAs are described in greater detai esewhere in this Discosure Statement. 9. No Prohibited Transactions. There are negative consequences if you enter into prohibited transactions with your HSA (e.g., you may not se, exchange, or ease property, borrow or end money, pedge the HSA, furnish goods, services or faciities, transfer to or use by or for your benefit any assets of the HSA). If you engage in a prohibited transaction with your HSA, the sanction, in genera, is disquaification of the HSA. Thus, the HSA stops being an HSA as of the first day of the taxabe year of the prohibited transaction. The assets of your HSA are deemed distributed, and the appropriate taxes, incuding the additiona 20 percent tax for distributions not used to pay for or reimburse quaified medica expenses, appy. 10. IRS Approva of Form. This Agreement incudes an IRS Forms 5305 series agreement. This IRS document has been approved by the IRS. This approva is not a determination of its merits, and not an endorsement of the investments provided by us or the operation of the HSA. 11. State Laws. State aws may affect your HSA in certain situations, incuding deductions, beneficiary designations, agency reationships, consent, taxes, tax withhoding, and reporting. HSA Eigibiity. 1. Eigibiity for an HSA. You are an eigibe individua and may make or receive an HSA reguar contribution if, with respect to any month, you: a. b. 2. c. d. are covered under a high-deductibe heath pan (HDHP); are not covered by any other type of heath pan that is not an HDHP (with certain exceptions for pans providing preventive care and imited types of permitted insurance and permitted coverage); are not enroed in Medicare; and may not be caimed as a dependent on another person' s tax return. High-Deductibe Heath Pan. Generay, an HDHP is a heath pan that provides significant benefits and satisfies certain requirements with respect to deductibes and out-of-pocket expenses. For purposes of this HSA, a high deductibe heath pan is a pan with a minimum annua deductibe and an out-of-pocket expense imit as foows: Tax Year HDHP Minimum Out-of-Pocket Coverage Deductibe Expense Limit 2014 Sef-Ony $ 1,250 $ 6,350 Famiy $ 2,500 $ 12, Sef-Ony $ 1,300 $ 6,450 Famiy $ 2,600 $ 12, Sef-Ony $ 1,300* $ 6,450* and ater Famiy $ 2,600* $ 12,900* *Subject to annua cost-of-iving adjustments, if any. A pan sha not fai to be treated as an HDHP by reason of faiing to have a deductibe for preventive care. An HDHP may therefore provide preventive care benefits without a deductibe or with a deductibe beow the minimum annua deductibe. Heath Savings Account Booket-Custodia Bankers Systems* VMP, Woters Kuwer Financia Services HSA-BK-C-LAZ 8/1/2014 Page 5 of 8

9 3. Permitted Insurance. You are eigibe for an HSA if you have coverage for any benefit provided by permitted insurance. An exampe of permitted insurance is insurance for a specific disease or iness, such as cancer insurance. In addition, you are eigibe for an HSA if you have coverage (whether provided through insurance or otherwise) for accidents, disabiity, denta care, vision care, or ong-term care. HSA Contributions. 1. Who Can Make Reguar or Annua Contributions. If you meet the eigibiity requirements for an HSA, you, your empoyer, your famiy members, or any other person (incuding nonindividuas) may contribute to your HSA. This is true whether you are sef-empoyed or unempoyed. 2. Reguar or Annua Contributions. a. Maximum Annua Contributions. In genera, the maximum annua contribution is the contribution imit based on HDHP coverage as shown in the foowing chart: Tax HDHP Contribution Catch-Up Tota Year Coverage Limit Contribution Contribution Limit Limit and ater Sef-Ony Famiy Sef-Ony Famiy Sef-Ony Famiy $ 3,300 $ 6,550 $ 3,350 $ 6,650 $ 3,350* $ 6,650* $ 1,000 $ 1,000 $ 1,000 $ 1,000 $ 1,000 $ 1,000 $ 4,300 $ 7,550 $ 4,350 $ 7,650 $ 4,350 * $ 7,650 * *Subject to annua cost-of-iving adjustments, if any. Your maximum annua contribution is generay determined by adding together your monthy contribution imits for the year. Your monthy contribution imit is determined on the first day of each month that you are an eigibe individua. A monthy contribution imit is 1/12 of the annua contribution imit based on your heath pan coverage (sef-ony or famiy) for such month. However, your maximum annua contribution may be a greater amount if you are an eigibe individua on the first day of the ast month (December 1 for caendar-year taxpayers). If so, you are treated as an eigibe individua for a months of the tax year and you may contribute up to such tax year' s annua contribution imit based on your HDHP coverage (sef-ony or famiy) on December 1 (for caendar-year taxpayers). If your maximum contribution amount determined under this method is greater than your monthy-determined maximum, and you contribute the greater amount, a testing period appies. The testing period for this provision begins with the ast month of the contribution year and ends on the ast day of the 12th month foowing such month (December 31 for caendar-year taxpayers). If you do not continue to be an eigibe individua for the entire testing period, uness you die or become disabed, the difference between your monthy-determined maximum and the amount you contributed is incudabe in your gross income for the year of faiure and is subject to a 10 percent penaty tax. For exampe, if you are an eigibe individua and enro in sef-ony HDHP coverage on January 1 but change to famiy HDHP coverage on November 1 and retain famiy HDHP coverage through December 31 of the same year, you may be abe to contribute up to the fu annua contribution imit for famiy coverage (pus catch-up if you are eigibe) because it is greater than the sum of the monthy contribution imits (10/12 of the sef-ony annua imit pus 2/12 of the famiy imit). b. Quaified HSA Funding Distribution. If you are an eigibe HSA individua, you may eect to take a quaified HSA funding distribution from your IRA (not incuding ongoing SEP and SIMPLE IRAs) to the extent such distribution is contributed to your HSA in a trustee-totrustee transfer. This amount is aggregated with a other annua HSA contributions and is subject to your annua HSA contribution imit. The contribution is made for the tax year of the distribution. A quaified HSA funding distribution eection is irrevocabe and is generay avaiabe once in your ifetime. A testing period appies. The testing period for this provision begins with the month of the contribution to your HSA and ends on the ast day of the 12th month foowing such month. If you are not an eigibe individua for the entire testing period, uness you die or become disabed, the amount of the contribution made under this provision wi be incudabe in gross income for the tax year of the month you are not an eigibe individua, and is subject to a 10 percent penaty tax. c. Annua Contributions Aggregated. If you have more than one HSA, the aggregate annua contributions to a the HSAs are subject to the contribution imit. This imit is decreased by the aggregate contributions to an Archer MSA. The same annua contribution imit appies whether the contributions are made by you, your empoyer, your famiy members, or any other person (incuding nonindividuas). Contributions may be made on your behaf even if you have no compensation or if the contributions exceed your compensation. d. Catch-Up Contributions. Catch-up contributions are HSA contributions made in addition to any reguar HSA contributions. You are eigibe to make catch-up contributions if you meet the eigibiity requirements for reguar contributions and are age 55 or oder by the end of your taxabe year and not enroed in Medicare. As with the annua contribution imit, the catch-up contribution is generay computed on a monthy basis. However, you may be eigibe to contribute the entire catch-up contribution amount even if you are not an eigibe individua for the entire tax year using the same first day of the ast month eigibiity rues and testing period appicabe to the annua contribution imit. 3. One or Both Spouses Have Famiy Coverage. You and your spouse are treated as having famiy coverage if one or both of you has famiy coverage. The contribution imit is divided equay between you and your spouse, uness each of you agree on a different division. The famiy coverage imit is reduced further by any contribution to an Archer MSA. However, each of you may make the catch-up contributions without exceeding the famiy coverage imit. 4. Contribution Deductibiity. a. Your Contributions. Contributions made by you to an HSA, which do not exceed the maximum annua contribution amount, are deductibe by you when determining your adjusted gross income. You are not required to itemize deductions in order to take this deduction. However, you cannot aso deduct the contributions as medica expenses under Interna Revenue Heath Savings Account Booket-Custodia Bankers Systems* VMP, Woters Kuwer Financia Services HSA-BK-C-LAZ 8/1/2014 Page 6 of 8

10 5. 6. Code (IRC) Section 213. Contributions by famiy members or any other person (incuding nonindividuas) on your behaf are aso deductibe by you. A contribution from an IRA is not deductibe. b. Empoyer Contributions. Empoyer contributions are treated as empoyer-provided coverage for medica expenses under an accident or heath pan and are excudabe from your gross income. The empoyer contributions are not subject to withhoding from wages for income tax or subject to the Federa Insurance Contributions Act (FICA), the Federa Unempoyment Tax Act (FUTA), or the Rairoad Retirement Tax Act. Contributions to your HSA through a cafeteria pan are treated as empoyer contributions. You cannot deduct empoyer contributions on your federa income tax return as HSA contributions or as medica expense deductions under IRC Section 213. Contribution Deadine. You or your empoyer may make reguar and catch-up HSA contributions any time for a taxabe year up to and incuding your federa income tax return due date, excuding extensions, for that taxabe year. The due date for most taxpayers is Apri 15. Return of Mistaken Distribution. If you mistakeny distribute assets from the HSA, our poicies may aow you to return the assets to the HSA. If you are abe to return a mistaken distribution, you wi need to be prepared to provide the IRS with cear and convincing evidence that the HSA distribution was the resut of a mistake of fact due to reasonabe cause. A mistaken distribution can be returned no ater than Apri 15 foowing the first year you knew or shoud have known the distribution was a mistake. Moving Assets To and From HSAs. There are a variety of transactions that aow you to move assets to and from your HSA. We have soe discretion on whether we wi accept, and how we wi process, movements of assets to and from HSAs. We or the other financia organization invoved in the transaction may require documentation for such activities. 1. HSA-to-HSA Transfers. You may transfer a or a portion of your HSA assets from one HSA to another HSA. An HSA transfer means that the HSA assets move from one HSA to another HSA in a manner that prevents you from cashing or iquidating the HSA assets, or even depositing the assets anywhere except in the receiving HSA. You may be required to compete a transfer authorization form prior to transferring your HSA assets. 2. Archer MSA-to-HSA Transfers. A transfer of Archer MSA assets to an HSA is permitted. However, HSA assets cannot be transferred to an Archer MSA. 3. HSA-to-HSA Roovers. An HSA roover is another way to move assets tax-free between HSAs. You may ro over a or a portion of your HSA assets by taking a distribution from an HSA and recontributing it as a roover contribution into the same or another HSA. Roovers to HSAs are not aowed from traditiona or Roth IRAs and empoyer-sponsored retirement pans. You must report your HSA roover to the IRS on your federa income tax return. Your contribution may ony be designated as a roover if the HSA distribution is deposited within 60 caendar days foowing the date you receive the distributed assets. You are imited to one roover per 1-year (12-month) period. You may ony ro over one HSA distribution per 1-year period aggregated between a of your HSAs. For exampe, if you have HSA 1, HSA 2, and HSA 3, and take a distribution from HSA 1 and ro it over into a new HSA 4, you wi have to wait 1 year from the date of that distribution to take another distribution from any of your HSAs and subsequenty ro it over into an HSA. 4. Archer MSA-to-HSA Roovers. Roovers from an Archer MSA to an HSA are permitted according to the same rues as HSA-to-HSA distributions and roovers. However, HSA assets cannot be roed over to an Archer MSA. HSA Distributions. You or, after your death, your beneficiary may take an HSA distribution, in cash or in kind based on our poicies, at any time. However, depending on the timing and amount of your distribution you may be subject to income taxes and/or penaty taxes. HSA custodians/trustees do not determine whether HSA distributions are used for quaified medica expenses. 1. Remova of Excess Contributions. You may withdraw a or a portion of your excess contribution and attributabe earnings by your federa income tax return due date, incuding extensions, for the taxabe year for which the contribution was made. The excess contribution amount distributed wi generay not be taxabe, but the attributabe earnings on the contribution wi be taxabe in the year in which the distribution is received. If you timey fie your federa income tax return, you may sti remove your excess contribution, pus attributabe earnings, as ate as October 15 for caendar year fiers. 2. Quaified Medica Expenses. Quaified medica expenses are expenses paid by you, your spouse, or your dependents for medica care as defined in section 213(d) or as otherwise permitted by aw, but ony to the extent the expenses are not covered by insurance or otherwise. The quaified medica expenses must be incurred ony after the HSA has been estabished. 3. Death. Upon your death, any baance remaining in your HSA becomes the property of the beneficiaries named in the HSA agreement. a. Spouse. If your spouse is the beneficiary of your HSA, the HSA becomes his/her HSA as of the date of your death. We may require your spouse to transfer the assets to an HSA of his/her own. Your spouse is subject to income tax ony to the extent distributions from the HSA are not used for quaified medica expenses. b. Nonspouse. If your beneficiary is not your spouse, the HSA ceases to be an HSA as of the date of your death. If your beneficiary is your estate, the fair market vaue of your HSA as of the date of your death is taxabe on your fina return. For other beneficiaries, the fair market vaue of your HSA is taxabe to them in the tax year that incudes such date. For such a person (except your estate), this amount is reduced by any payments from the HSA made for your quaified medica expenses, if paid within one year after your death. 4. Remova of Empoyer Contributions. If your empoyer contributes an amount in excess of the maximum annua contribution amount, or if your empoyer makes a contribution to your HSA but you were never an eigibe individua, your empoyer may request a distribution from your HSA to correct the error. Heath Savings Account Booket-Custodia Bankers Systems* VMP, Woters Kuwer Financia Services HSA-BK-C-LAZ 8/1/2014 Page 7 of 8

11 Federa Income Tax Status of Distributions. 1. Taxation. Distributions from your HSA used excusivey to pay for or reimburse quaified medica expenses of you, your spouse, or your dependents are excudabe from gross income. In genera, amounts in an HSA can be used for quaified medica expenses and wi be excudabe from gross income even if you are not currenty eigibe for contributions to the HSA. However, any amount of the distribution not used excusivey to pay for or reimburse quaified medica expenses of you, your spouse, or your dependents is incudabe in your gross income and is subject to an additiona 20 percent tax penaty on the amount incudabe, except in the case of distributions made after your death, your disabiity, or your attainment of age 65. HSA distributions which are not roed over wi be taxed as income in the year distributed, uness they are used for quaified medica expenses. You may aso be subject to state or oca taxes and state withhoding on your HSA distributions. 2. Earnings. Earnings, incuding gains and osses, on your HSA wi not be subject to federa income taxes unti they are considered distributed. 3. Ordinary Income Taxation. Your taxabe HSA distribution is usuay incuded in gross income in the distribution year. Estate and Gift Tax. The designation of a beneficiary to receive HSA distributions upon your death wi not be considered a transfer of property for federa gift tax purposes. Upon your death, the vaue of a assets remaining in your HSA wi usuay be incuded in your gross estate for estate tax purposes, regardess of the named beneficiary or manner of distribution. There is no specific estate tax excusion for assets hed within an HSA. Annua Statements. Each year we wi furnish you and the IRS with IRS-required statements refecting the activity in your HSA. Federa Tax Penaties. Severa tax penaties may appy to your various HSA transactions, and are in addition to any federa, state, or oca taxes. Federa penaties and excise taxes are generay reported and remitted to the IRS aong with your federa income tax return. The penaties may incude any of the foowing taxes: 1. Additiona Tax. Any amount of a distribution not used excusivey to pay for or reimbruse quaified medica expenses of you, your spouse, or your dependents is subject to an additiona 20 percent tax on the amount incudabe in your gross income, except in the case of distributions made after your death, your disabiity, or your attainment of age 65. Separatey, any faiure to meet a required testing period resuting in amounts incudabe in gross income wi make such amounts subject to an additiona 10 percent tax. 2. Excess Contribution Penaty Tax. If a contribution to your HSA exceeds the amount you are eigibe for, you have an excess contribution, which is subject to a 6 percent excise tax. The excise tax appies each year that the excess contribution remains in your HSA. Heath Savings Account Booket-Custodia Bankers Systems* VMP, Woters Kuwer Financia Services HSA-BK-C-LAZ 8/1/2014 Page 8 of 8

12 ELECTRONIC FUND TRANSFERS YOUR RIGHTS AND RESPONSIBILITIES The Eectronic Fund Transfers we are capabe of handing for consumers are indicated beow, some of which may not appy to your account. Some of these may not be avaiabe at a terminas. Pease read this discosure carefuy because it tes you your rights and obigations for these transactions. You shoud keep this notice for future reference. TYPES OF TRANSFERS, FREQUENCY AND DOLLAR Make payments from LIMITATIONS to (a) Prearranged Transfers. Get checking account(s) information Preauthorized credits. You may make arrangements Get savings account(s) information for certain direct deposits to be accepted into your Some of these services may not be avaiabe at a terminas. checking and/or savings account(s). Preauthorized payments. You may make arrangements to pay certain recurring bis from your checking and/or savings account(s). (d) Point-Of-Sae Transactions. Using your card: You may access your checking account (b) Teephone Transfers. You may access your account(s) account(s) to purchase by teephone at goods ( in person, by phone, by computer), using a touch tone phone, your account numbers, and pay for services ( in person, by phone, Your Persona Identification Number to: by computer), get cash from a merchant, if the Transfer funds from checking to savings merchant permits, or from a participating financia Transfer funds from savings to checking institution, and do anything that a participating Transfer funds from oan accounts merchant wi accept. to checking You may not exceed more than $ 3,000 in Transfer funds from oan accounts to savings Make payments from checking to oan accounts with us Make payments from savings to oan accounts with us Make payments from to Get checking account(s) information Get savings account(s) information (c) ATM Transfers. You may access your account(s) by ATM using your ATM and/or Debit Card and persona identification number to: Make deposits to checking accounts Make deposits to savings accounts Get cash withdrawas from checking accounts you may withdraw no more than $ per day Get cash withdrawas from savings accounts you may withdraw no more than $ per day Transfer funds from savings to checking Transfer funds from checking to savings Transfer funds from to Make payments from checking account to (e) Computer Transfers. You may access your account(s) by computer by visiting X transactions per day on pin based transactions. The. amount on hod for signature based transactions combined with pin based transactions can not exceed $3,000.00, $ for Easy Student Debit Card, $1, for HSA Debit Card and using your to: Transfer funds from checking to savings Transfer funds from savings to checking Transfer funds from your account with Guf Coast Bank to your account with another financia institution Transfer funds from to Make payments from checking to oan accounts with us Make payments from your account with Guf Coast Bank to Pay Bis Make payments from your account with Guf Coast Bank to pay individuas Get checking account(s) information Get savings account(s) information user name and password Transfer funds from your account with another institution to your account with Guf Coast Bank Transfer funds from checking to checking and from savings to savings Eectronic Fund Transfers Discosure ETM-2-LAZ 10/18/2014 Bankers Systems * VMP, Woters Kuwer Financia Services Page 1 of 5