Form Hsa 02 PDF Details

In the landscape of financial and health planning, the designation of beneficiaries for a Health Savings Account (HSA) embodies a significant step in managing one’s estate effectively. The HSA-02 form serves as a cornerstone for account holders wishing to designate or change beneficiaries for their HSA, ensuring that in the event of their death, the account's funds are distributed according to their wishes. This form allows for the nomination of both primary and contingent beneficiaries, detailing the specific percentage of assets to be allocated to each, provided the allocations sum up to 100%. In instances where a designated primary beneficiary predeceases the account holder, their share is proportionally redistributed among the surviving beneficiaries. Moreover, the form acknowledges the crucial role of spousal consent in community or marital property states, where designating someone other than the spouse necessitates their agreement. The HSA-02 form, therefore, not only acts as a tool for financial foresight but also aligns with legal requirements to ensure the intended distribution of assets.

QuestionAnswer
Form NameForm Hsa 02
Form Length2 pages
Fillable?No
Fillable fields0
Avg. time to fill out30 sec
Other nameschase bank beneficiary form, chase beneficiary, chase add beneficiary, chase account beneficiary

Form Preview Example

Health Savings Account

With HSA Debit Card

Designation of Beneficiary for Health Savings Account

Health Savings Account #: 397 _ _ _ _ _ _ _ _ _

Account Holder Name: __________________________, _______________________, _____

 

(Last)

(First)

(MI)

Mailing Address:

 

 

 

Street:

_______________________________________________________

Apt. #:

_______________________________________________________

City:

________________________

State: ___________

 

Zip Code:

__________-_____________

 

 

Daytime Telephone #: ___________________ SS#: ______ - _____ - ___________

Beneficiary Designation

Please list one or more primary beneficiaries for your Health Savings Account (HSA) referenced above or any successor to this HSA, indicating the beneficiary percentage that should be provided to each primary beneficiary in the event of your death (the percentages should add to 100%). If a primary beneficiary should predecease you, his or her interest, as well as the interests of his or her heirs, will terminate completely and the percentage share of the surviving primary beneficiaries will be increased on a pro-rata basis. If you do not designate beneficiaries, or if the total percentage designated for your beneficiaries is less than 100% of your HSA, the remaining HSA funds will become part of your estate after your death. Please refer to your Health Savings Custodial Account Agreement for more detailed provisions regarding beneficiaries. This beneficiary designation is effective upon receipt by Chase and unless otherwise specified cancels all previous designations on file with Chase.

Primary Beneficiary 1

Name:

___________________________

Relationship:

_________________________

Address:

______________________

Social Security #

_______ -

____ - _______

 

______________________

 

 

 

City:

___________________________

State, Zip Code

_______

_________ - ______

Telephone #:

___________________________

Beneficiary %

_______

 

 

 

 

 

Primary Beneficiary 2

 

 

 

 

 

 

 

Name:

___________________________

Relationship:

_________________________

Address:

______________________

Social Security #

_______ -

____ - _______

 

______________________

 

 

 

City:

___________________________

State, Zip Code

_______

_________ - ______

Telephone #:

___________________________

Beneficiary %

_______

 

 

 

 

 

Primary Beneficiary 3

 

 

 

 

 

 

 

Name:

___________________________

Relationship:

_________________________

Address:

______________________

Social Security #

_______ -

____ - _______

 

______________________

 

 

 

City:

___________________________

State, Zip Code

_______

_________ - ______

Telephone #:

___________________________

Beneficiary %

_______

 

HSA-02 09/20/06

Health Savings Account

With HSA Debit Card

Designation of Beneficiary for Health Savings Account, continued

Contingent beneficiaries will receive your HSA assets in the event that all of your primary beneficiaries predecease you. Please list one or more contingent beneficiaries, together with the percentage of your HSA assets that each should receive (the percentages you list for all contingent beneficiaries should sum to 100%).

Contingent Beneficiary 1

Name:

___________________________

Relationship:

_________________________

Address:

______________________

Social Security #

_______ -

____ - _______

 

______________________

 

 

 

City:

___________________________

State, Zip Code

_______

_________ - ______

Telephone #:

___________________________

Beneficiary %

_______

 

 

 

 

 

Contingent Beneficiary 2

 

 

 

 

 

 

 

Name:

___________________________

Relationship:

_________________________

Address:

______________________

Social Security #

_______ -

____ - _______

 

______________________

 

 

 

City:

___________________________

State, Zip Code

_______

_________ - ______

Telephone #:

___________________________

Beneficiary %

_______

 

SPOUSAL CONSENT:

Your spouse’s signature is required below if you are married, have your legal residence in any community or marital property state (Arizona, California, Idaho, Louisiana, Nevada, New Mexico, Texas, Washington or Wisconsin) and you have designated someone other than, or in addition to, your spouse as beneficiary. If you do not obtain your spouse’s signature, you warrant none is required:

X__________________________________________________

_________________

Spouse’s Signature

Date Signed

____________________________________________________

 

Print Name

 

Please forward this completed form to:

JPMorgan Chase Bank, N.A.

HSA Operations

P.O. Box 30207

Tampa, FL 33630-3207

For questions about account beneficiary matters, please contact HSA Member Services at 866-524-2483.

X

_____

 

 

Signature of Account Holder

 

 

Date Signed

HSA-02 09/20/06

How to Edit Form Hsa 02 Online for Free

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The PDF file you are going to create will cover the following areas:

stage 1 to completing chase bank beneficiary form

Include the demanded particulars in the Primary Beneficiary, Name, Address, City, Relationship, Social Security, State Zip Code, Telephone, Beneficiary, Primary Beneficiary, Name, Address, City, Relationship, and Social Security part.

Finishing chase bank beneficiary form stage 2

It is vital to write down specific information within the area Contingent Beneficiary, Name, Address, City, Relationship, Social Security, State Zip Code, Telephone, Beneficiary, Contingent Beneficiary, Name, Address, City, Relationship, and Social Security.

Filling out chase bank beneficiary form step 3

As part of space SPOUSAL CONSENT Your spouses, X Spouses Signature, Date Signed, Print Name, Please forward this completed form, JPMorgan Chase Bank NA HSA, For questions about account, X Signature of Account Holder, and X Date Signed, specify the rights and obligations.

Finishing chase bank beneficiary form part 4

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