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Form 5305C: Health Savings Custodial Account
IRS Form 5305-C is a model custodial account agreement approved by the IRS for establishing a Health Savings Custodial Account under section 223(a) of the Internal Revenue Code. Contributions are subject to an excise tax if in excess of the maximum annual limit.
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IRS Form 5305C - Health Savings Custodial Account
IRS Form 5305-C is a model custodial account agreement approved by the IRS for establishing a Health Savings Custodial Account under section 223(a) of the Internal Revenue Code. Contributions are subject to an excise tax if in excess of the maximum annual limit.
Risk Radar
Scan points- 1Do not file this agreement with the IRS; keep it in your records instead.
- 2Failing to state the account owner's Date of birth on Form 5305-C.
- 3Not listing the full Street address, city, state, and ZIP code for the account owner.
- 4Omitting confirmation that the owner is covered under a high deductible health plan (HDHP).
- 5Failing to sign before sending/keeping the completed Form 5305-C.
Plain English
This form officially sets up a Health Savings Custodial Account (HSA) for someone else. It confirms that the account owner is eligible to contribute and specifies how the funds will be used for medical expenses. The agreement must be completed by both the account owner and the custodian before the HSA can begin functioning.
Submission Date
- Filing date: 2017-02-08 00:00:00
- Preparation window: collect IDs, supporting records, and signatures in advance.
- Final review: verify names, dates, and required fields before submission.
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What this form is for
- Use this form when establishing a Health Savings Custodial Account (HSA) in the United States for the exclusive benefit of an account owner.
- Do not use this form when the HSA is established outside of the United States, as it must be created here.
- Check Form 5305-C instead when you need to establish a custodial account under section 223(a) of the Internal Revenue Code.
Form selector
Use this form or another form?
Need to report unrelated business taxable income for an HSA
The form requires an Employer Identification Number (EIN) if it is used for filing a return reporting this income.
✓ Check Article IX
Creating a common fund for HSAs
An EIN must be provided for the custodial account when it functions as a common fund for Health Savings Accounts.
✓ Check Form 5305-C (Rev. 10-2016)
Need to document specific amendments or additional provisions
Any additional article added to this agreement must comply with the requirements of Article IX, which governs the controlling provisions.
✓ Check Articles I through VIII
Deadline or filing window
The deadline for making contributions is before the filing of the account owner’s federal income tax return for that year, and extensions are allowed. For calendar year 2011, the maximum annual contribution limit increases to $3,100 for single coverage and $6,250 for family coverage in 2012.
Checklist
What you need before filling it out
Account Owner's SSN
Account owner’s social security number · Identifying Number section (Form p.2)
Custodian Type
Bank, insurance company, or IRS-approved IRA/Archer MSA custodian · Custodian definition (Form p.2)
Contribution Limit
Maximum amount for family coverage plus the catch-up contribution · Article I, Section 1 (Form p.1)
Distribution Purpose Substantiation
Account owner must maintain records sufficient to show distribution is tax-free and for qualified medical expenses · Article I, Section 2 (Form p.1)
Before you submit
- 1Confirm the account owner’s social security number is entered as the identifying number.
- 2Verify that the custodian listed is an approved entity (bank, insurance company, etc.).
- 3Check that any cash contributions do not exceed the maximum amount for family coverage plus the catch-up contribution.
- 4Ensure both the account owner and custodian have signed the form.
- 5If required by local rules, confirm a witness signature is present.
- 6Verify Article I, Section 2 confirms the account owner will substantiate distributions as qualified medical expenses.
- 7Confirm that the agreement specifies it was created for the exclusive benefit of the account owner in the United States.
How to file this form
- 1Complete all required fields, including entering the identifying number (account owner’s SSN) and confirming the custodian's details.
- 2Sign and date the form as both the Account Owner and the Custodian.
- 3If necessary, have a witness sign and date the agreement.
- 4Keep the fully executed Form 5305-C with your records (do not file it with the IRS).
- 5Use this completed agreement to establish the Health Savings Account.
Known limitations
- 1The account owner must establish this Health Savings Custodial Account exclusively for the benefit of the account owner in the United States.
- 2If the beneficiary is not the account owner’s spouse, the Health Savings Account (HSA) ceases to be an HSA as of the date of death.
- 3For other beneficiaries (other than the spouse or estate), the fair market value of the account is taxable to that person in the tax year that includes the date of death.
- 4If the account owner dies before the entire interest is distributed and the beneficiary is the account owner’s estate, the fair market value of the account as of the date of death is taxable on the account owner’s final return.
Field map
Compact field-by-field guide
General Info
2 items
Full legal name and taxpayer identification number (SSN or EIN).
Current mailing address.
Details
2 items
Complete all applicable sections of this form according to the official IRS instructions.
Enter the relevant dollar amount if this form involves tax calculation.
Certification
1 items
Read and acknowledge any certifications required by this form.
Signatures
1 items
Sign and date. Unsigned forms cannot be processed.
Almost done reviewing the fields?
Fillable formOpen in Editor->The current edition is Revision 10-2016, dated October 16. The form includes a 'What's New' section detailing an increase in the additional tax rate for distributions not used for qualified medical expenses to 20% for tax years beginning after December 31, 2010.
What changed or needs a fresh check
- Edition date — confirm the revision reads 10-2016
- Form number — confirm the title is IRS Form 5305C and the part number is Cat. No. 38257X
- Signature — ensure both Account owner and Custodian signatures are present (Witness signature is optional)
- Tax Year Start — verify that contributions fall within a tax year beginning after December 31, 2010, to confirm the 20% additional tax rate applies.
- Jurisdiction — confirm the agreement specifies it was created in the United States.
Quick Facts
Downloads
After you file
- 1Keep a copy of the executed Form 5305-C with your records.
- 2The form can be completed at any time during the tax year.
- 3Confirm that the agreement is fully executed by both the account owner and the custodian to establish the HSA.
- 4If an additional article is added, confirm it complies with the requirements of Article IX (controlling provisions).
- 5Note that if the account owner or custodian requires witnessing their signature, a Witness' signature must be included.
Sources
- SRCForm 5305-C is a model custodial account agreement approved by the IRS (Instructions p.2).
- SRCThe form establishes an HSA under section 223(a) of the Internal Revenue Code (Instructions p.1).
- SRCDo not file Form 5305-C with the IRS; instead, keep it with your records (Instructions p.2).
- SRCThe account owner must be covered under a high deductible health plan (HDHP) to establish this HSA (Instructions p.1).
- SRCFor tax years beginning after December 31, 2010, the additional tax on distributions not used for qualified medical expenses increases from 10% to 20% (Instructions p.2).
- SRCThe account owner is responsible for substantiating that a distribution is for qualified medical expenses and must maintain records (Instructions p.1).
- SRCIf the beneficiary is the account owner’s spouse, the HSA becomes the spouse’s HSA as of the date of death (Article VII, Item 1 on Instructions p.2).
- SRCThe account owner’s social security number serves as the identification number of this HSA (Definitions on Instructions p.2).
Common confusion points
Where do I send this form?
The source states not to file it with the IRS.
→ Keep the executed Form 5305-C with your records.
What is required for the account owner to qualify?
The account owner must be covered under a High Deductible Health Plan (HDHP) and meet other criteria.
→ Check that all four conditions listed in Article I are met.
Who determines if a distribution is 'qualified'?
Only the account owner is responsible for substantiating that the distribution is for qualified medical expenses.
→ The custodian does not need to determine this; the account owner must maintain records.
What happens to the tax rate on distributions?
For tax years beginning after December 31, 2010, the additional tax increases from 10% to 20%.
→ Verify that your contribution date falls under the post-12/31/2010 rule.
What is my identification number?
The account owner’s social security number serves as the identification number of this HSA.
→ If married, each eligible spouse must establish their own account.
When does the agreement become effective?
An HSA is established after the form is fully executed by both the account owner and the custodian.
→ Ensure all required signatures (Owner, Custodian) are present before use.
Workflow map
Related forms and next steps
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After
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⚠ If something goes wrong
- Article XI may be used for any additional provisions that comply with Article IX.
Questions about IRS Form 5305C
What is IRS Form 5305C used for?
This form officially sets up a Health Savings Custodial Account (HSA) for someone else. It confirms that the account owner is eligible to contribute and specifies how the funds will be used for medical expenses. The agreement must be completed by both the account owner and the custodian before the HSA can begin functioning.
Who must file IRS Form 5305C?
The form is established by an account owner who designates a custodian, establishing this health savings account (HSA) exclusively for their benefit.
What information does IRS Form 5305C require?
The form collects specific details such as the name and address of the account owner and custodian. It also requires documentation regarding the eligibility criteria, including confirmation that the account owner is covered under a high deductible health plan (HDHP).
When is IRS Form 5305C due?
The form can be completed at any time during the tax year before the deadline for filing the account owner’s federal income tax return for that year (without extensions).
Where do I file IRS Form 5305C?
Do not file Form 5305-C with the Internal Revenue Service; instead, keep it with your records. The agreement must be created in the United States.
How do I complete IRS Form 5305C?
First, the account owner provides personal details and represents their eligibility under an HDHP. Next, the custodian provides their business information. Finally, both parties must sign the form, with a witness signature being required only if the signature of the account owner or custodian is required to be witnessed.
What happens if IRS Form 5305C is filed incorrectly?
Contributions made into the account that exceed the maximum annual contribution limit are subject to an excise tax.
Where do I send this form?
The source states not to file it with the IRS. Keep the executed Form 5305-C with your records.
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