By electronically signing, I certify that:
- I am, or will be covered by a qualified High Deductible Health Plan (HDHP), I am not enrolled in Medicare or covered under other health insurance that is not compatible with an HSA, and I may not be claimed as a dependent on another person’s tax return (excluding spouses per the IRS).
- Avidia Bank is hereby appointed to serve as custodian of my Health Savings Account.
- I have reviewed and agree to the following Agreements and Disclosures; Deposit Account Agreement, Health Savings Custodial, Funds Availability, Electronic Funds Transfer, Check 21. Truth in Savings and Privacy Statement.
- Within seven (7) calendar days from the date I open this HSA, I may revoke authorization for opening the account by mailing a written notice to Avidia Bank, P.O. BOX 370, Hudson MA 01749.
- To help the government fight the funding of terrorism and money laundering activities, Federal Law requires that all financial institutions obtain, verify and record information that identifies each person who opens an account. What this means to you: when you open an account we will need you and your authorized signer to provide name, street address, date of birth and other information that will allow us to identify you and your authorized signer. We may also ask to see your driver’s license or other identifying documents.
- I understand account statements are delivered electronically and I can change delivery preference once enrolled for online access
- The number shown on this form is my correct taxpayer identification number (or I am waiting for a number to be issued to me).
- I am not subject to backup withholding because: (a) I am exempt from backup withholding, or (b) I have not been notified by the Internal Revenue Service (IRS) that I am subject to backup withholding as a result of a failure to report all interest or dividends, or (c) the IRS has notified me that I am no longer subject to backup withholding.
- I am a U.S. citizen or other U.S. person.
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