INSTRUCTIONS AND TERMS FIDELITY HSASM Checkwriting Form Signature Card by Yearoveryear



FIDELITY HSASM Checkwriting Form (Signature Card)
Use this form to:
• add checkwriting to your Fidelity Health Savings Account (HSA)

  Before You Begin
  All information is required If you do not provide all                 We will print the HSA custodian’s name and your name
  information — and the necessary signature — your request              and address on all your checks. Make sure the address you
  will be delayed. You need to complete a separate form for             have on file with Fidelity is correct, as checkbooks will be sent
  each account.                                                         to your address of record.
  Any checks that you write on your HSA are considered                  Do not use a check to close your HSA.
  HSA distributions and will be reported to the IRS on Form             Cancelled checks are not returned to you. Instead, all
  1099-SA. You must file IRS Form 8889 when you file your               checking activity will be reported on your statement. To get
  federal income tax returns. Keep in mind that while you may           a copy of a check, call us or visit our Web site (see below).
  take distributions from your Fidelity HSA at any time, any part       You may be charged a fee.
  of a distribution not used to pay qualified medical expenses
  is includable in gross income and is subject to an additional         If you write a check that exceeds the available amount
  10% tax unless an exception applies. You are responsible              in your core account, the check may be returned.
  for maintaining sufficient records in determining distributions       Checkwriting is available only on the core account. Your core
  used to pay for qualified medical expenses.                           account must have sufficient funds to cover checks written.

Terms and Conditions
By signing the form, you:                   • Authorize the Bank to direct Fidelity           • Understand that you will be responsible
• Agree to be bound by the current and        Brokerage Services LLC (FBS), or                  for payment to the IRS (as well as any
  future terms and conditions, guide-         National Financial Services LLC (NFS)             applicable state and local taxing author-
  lines, and rules applicable to your         (or its successor(s)), as applicable, as the      ity) for any income taxes, and the 10%
  account, including those of the fund(s),    Custodian, and Fidelity Trust Company             penalty for distributions not used for
  the Fidelity HSA Custodial Agreement,       (or its successor custodian(s)), to redeem        qualified medical expenses (unless an
  UMB Bank, N.A. (“the Bank”), and the        shares and make the necessary distribu-           exception applies), due on distributions
  Uniform Commercial Code as enacted          tions from your Fidelity HSA to pay the           resulting from checks that you write.
  in the State of Missouri, as they pertain   check.                                          • Agree not to write any checks and/or
  to the use of redemption checks.          • Agree that in acting in accordance with           request distributions that in total would
• Authorize and request UMB Bank,             this agreement, the Bank is liable only           exceed the balance of the core account
  N.A. (the “Bank”), to provide you with      for its own negligence.                           in your HSA.
  checks to be written on your core         • Agree to be bound by the Fidelity Cash          • Indemnify the Custodian for the Fidelity
  account in your Fidelity HSA identified     Reserves prospectus and the Fidelity              HSA, it agents, successors, affiliates, and
  on this form and to accept checks           Brokerage Customer Agreement.                     employees from any liability in the event
  presented for payment.                                                                        you fail to meet the IRS requirements.
                                                                                              • Understand that this authorization may
                                                                                                be terminated by you at any time by writ-
                                                                                                ten notification to FBS for a Fidelity HSA.
                                                                                                Any such notification shall be effective
                                                                                                only with respect to entries after receipt
                                                                                                of such notification and a reasonable
                                                                                                time to act on it.

A copy of the “United Missouri Bank Statement of Terms and Conditions” applicable to your account will be enclosed with your
initial check order.

Questions? Go to or call 1-800-544-3716.
Keep these instructions for your records. Do not return them to Fidelity.
UMB Bank, N.A., is an independent organization not affiliated with Fidelity.
Fidelity HSASM Checkwriting Form (Signature Card)
Enter information on screen, or print the form and fill out by hand. Write clearly in black ink.

1. Fidelity Account
Account Number
                                                                         Write the number of the Fidelity Health Savings Account to which you want to add checkwriting.

2. Required Signature
By signing below, you instruct Fidelity to act on all instructions given on this form, and you agree to accept all terms and conditions
on this form and on the “Instructions and Terms” page that accompanies it.

Owner/Authorized Individual’s Name and Signature:
Type or Print Owner/Authorized Individual’s Name (First, Middle, Last)

 Signature                                                                                                                                                Date MM / DD / YYYY


Questions? Go to or call 1-800-544-3716.
Form completed and signed?
Use the enclosed envelope or mail to Fidelity Investments, PO Box 770001, Cincinnati, OH 45277-0002.

On this form, “Fidelity” means Fidelity Brokerage Services LLC and its affiliates. Brokerage services are provided by Fidelity Brokerage Services LLC, Member NYSE, SIPC.

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                   1.821924.101                                                                                                          013380101

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