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/depts/uwhealth/benefits/open-enrollment/uwmf-open-enrollment/health-savings-account/resources/OE-HSA-Death-Beneficiary-Form.pdf

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Departments & Programs,UW Health,Benefits,UW Health Open Enrollment,UWMF Open Enrollment,Health Savings Account,Resources

HSA - Death Beneficiary Form

HSA - Death Beneficiary Form - Departments & Programs, UW Health, Benefits, UW Health Open Enrollment, UWMF Open Enrollment, Health Savings Account, Resources


Health Savings Account (HSA) Death Beneficiary Change Form
This form is to make changes to beneficiary designations. Please note: in order to process this form, notarization is required.
*=Required Fields
Step 1: Account Holder Information
Step 2: Designation of Death Beneficiary/Beneficiaries
Step 3: Marital Status
*Account Holder Name (First, MI, Last)
*Employer Name (Do not abbreviate) Employee ID
New Death Beneficiary(ies): The following individual(s) or entity shall be my primary and/or contingent death beneficiary(ies). If neither primary nor
contingent is indicated, the individual or entity will be deemed to be a primary death beneficiary.
Replace Death Beneficiary(ies): I designate the individual(s) or entity named below as my primary and/or contingent death beneficiary(ies) of this HSA and
hereby revoke all prior death beneficiary(ies) designations, if any, made by me.
Add Death Beneficiary(ies): I designate the individual(s) or entity named below as my primary and/or contingent death beneficiary(ies) of this HSA. This list
supplements, but does not replace, the death beneficiary(ies) previously designated by me on the date specified.
Note: When adding death beneficiaries, if the share % of previously designated death beneficiary(ies) changes, restate all death beneficiaries and the
corresponding share % if the previous percentages are no longer correct.
*Social Security Number
--
www.DiscoveryBenefits.com
866-451-3399 · 866-451-3245
PO Box 2926 · Fargo, ND 58108-2926
customerservice@discoverybenefits.com
If neither primary nor contingent is indicated, the individual or entity will be deemed to be a primary death beneficiary. If any primary or contingent death
beneficiary dies before me, his or her interest and the interest of his or her heirs shall terminate completely, and the percentage share of any remaining death
beneficiary(ies) shall be increased on a pro rata basis. If more than one primary death beneficiary is designated and no distribution percentages are indicated,
the death beneficiaries will be deemed to own equal share percentages in the HSA. Multiple contingent death beneficiaries with no share percentage indicated
will also be deemed to share equally. If no primary death beneficiary(ies) survives me, the contingent death beneficiary(ies) shall acquire the designated share
of my HSA.
I am the spouse of the above-named HSA Account Beneficiary. I acknowledge that I have received a fair and reasonable disclosure of my spouse’s property and
financial obligations. Due to the important tax consequences of giving up my interest in this HSA, I have been advised to see a tax professional. I hereby give the
HSA Account Beneficiary any interest I have in the funds or property deposited in this HSA and consent to the death beneficiary designation(s) indicated above. I
assume full responsibility for any adverse consequences that may result. No tax or legal advice was given to me by the Custodian.
Name Social Security
Number
Birth Date Address Primary or
Contingent
Relationship Share %
Primary
Primary
Contingent
Contingent
I am not married: I understand that if I become married in the future, I must complete a new HSA Designation of Death Beneficiary Form.
I am married: I understand that if I choose to designate a primary death beneficiary other than my spouse, my spouse must sign below and have his/her
signature notarized.
Spouse Signature Date
� � � � � � � � � � � �
Open Enrollment 2018

HSA Death Beneficiary Change Form, continued
www.DiscoveryBenefits.com
866-451-3399 · 866-451-3245
PO Box 2926 · Fargo, ND 58108-2926
customerservice@discoverybenefits.com
Step 4: Spouse’s Signature Notarization (only required if spouse is not the designated beneficiary)
Step 5: Authorized HSA Account Holder Signature
State of
Notary Public Signature (seal)
County of
On this, the day of , 20 , before me a notary public, , personally
appeared , satisfactorily proved to be the person whose name is subscribed to the within instrument, and acknowledged that
he/she executed the same for the purposes therein contained.
In witness hereof, I hereunto set my hand and official seal.
If this HSA is being established with a regular contribution, I certify that I am covered by a qualified high deductible health plan
(HDHP), and that I am not covered by a health plan other that an HDHP that provides any of the same benefits as an HDHP. If this
HSA is being established with a rollover or transfer contribution, I certify that the rollover or transfer assets are from another HSA
or Archer Medical Savings Account (MSA). I certify that the information provided by me on the Application is accurate, and that I
have received a copy of the Application and Custodial Agreement and Disclosure Statement and amendments thereto. I assume
sole responsibility for all consequences found in the Application and Custodial Agreement and Disclosure Statement. I understand
that I may revoke the HSA on or before seven (7) days aber the date of establishment. I have not received any tax or legal advice
from the Custodian, and I will seek the advice of my own tax or legal professional to ensure my compliance with related laws. I
release and agree to hold the HSA custodian harmless against any and all claims or losses arising from my actions.
*HSA Account Holder Signature *Date
Revised 5/11/15