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MEDICAL SAVINGS ACCOUNTS / HEALTH SAVINGS ACCOUNTS
OF UTAH, INC.
ADMINISTRATOR OF UTAH
P.O. BOX 65625
SALT LAKE CITY, UTAH  84165-9867

HEALTH SAVINGS ACCOUNTS ADMINISTRATOR OF UTAH, INC.
 

The Depositor whose name appears on the M.S.A./H.S.A. application is establishing a Health Savings Account under section 223(d) to provide for their uninsured medical expenses.   Medical withdrawals for any medical expense qualifying under Section 213(d) of the Internal Revenue Code may be paid.

Account Holder:
___________________________________________________________________________________________
Name
___________________________________________________________________________________________
Address
___________________________________________________________________________________________
City                                                    County                                      State                      Zip Code

This  Health Savings Account Agreement ("Agreement") is entered into by and between Health Savings Account Administrator of Utah, Inc.  ("Administrator") and Account Holder.  Account Holder hereby agrees to open and maintain a Medical Care Savings Account ("Account") and the Administrator agrees to administer such Account Holder in compliance with the health insurance Portability and Accountability Act of 1996 I.R.S. Bill H.R. 3101 et seq. (the "Act") and under the following term and conditions:
 
 
I.     The   Account Holder:
        A.    Agrees to take such necessary steps and execute such documents as
                 Administrator deems necessary to open a Health Savings Account
        B.    (The Account) with Utah depository institution of the Administrator's
                 choice and grant Administrator full authority to make such deposits and
                 withdrawals as required under this agreement.
        C.   Agrees to pay to Administrator contributions into the Account as follows:

               _______________________________________________________________________

               _______________________________________________________________________
 
                 Account Holder may make additional payments to Administrator for deposit
                 in the account at any time.
                 Agree to pay administrator a fee for performing the administration
                 services under this agreement of 10.00 per month. 
         D.   Agrees that the Administrator may collect the administration fee  from the
                 Account on a periodic basis as determined by the Administrator.
         E.   Agrees to request in writing the payments to be made by Administrator from
                 the Account for Account Holder's Eligible Medical Expenses ( as defined in
                 to Act ) on such forms and with such supporting information as
                 Administrator shall request to verify the eligibility of the requested payments.
          F.    Authorizes Administrator to reimburse Account Holder or service provider
                 directly for eligible medical expenses incurred.
         G.   Agrees Administrator shall not be responsible in any way for failure to make
                 payments requested by Account holder due to insufficient funds in the
                 Account.
         H.    Has read and fully understands the Summary of Health Savings
                 Account attached hereto and incorporated herein as Exhibit A, including
                 specifically the terms and conditions under which amounts contributed to the
                 Account may be deductible from the Health Savings Account Holder's income for I.R.S.
                 income tax purposes and that withdrawals from the Account may be
                  subject to taxation and/or withdrawals penalties.
           I.    Is required  to pay the I.R.S. directly for any penalties levied under the act.
           J.   Has had the opportunity to consult with a tax advisor regarding the tax
                 effects of using Health Savings Account and has not relied on
                 Administrator for legal advise.
           K.  Agrees Administrator shall in no way be liable to Account Holder for any
                 cost, loss or expense suffered by Account Holder in connection with a
                 determination by Administrator or ( or an I.R.S. tax authority ), that medical
                 expenses Account Holder requests for payment from the Account do not
                 qualify as Eligible medical Expenses as defined in the Act.
 
II.  ADMINISTRATOR:
 
        A.    Agrees to administer Account Holder's Account in accordance with the act
                 and the rules and regulation promulgated there under
        B.    Agrees to provide the Account Holder with a statement documenting each
                 payment requested by Account Holder and the Account balance after each
                 payment and fee withdrawal made by Administrator.
 
III  Termination:
 
         A.   Administrator may terminate this agreement by giving  thirty (30) days
                 written notice of termination to Account Holder.  With thirty (30) days
                 following notice of termination by Administrator, Account holder shall either
                 (i) instruct Administrator to close the Account and distribute to Account
                 Holder funds remaining in account on the dated the Account is closed less
                 administrative fees due Administrator and withdrawal penalties required
                 under the Act; or (ii.), designate in writing to Administrator a new
                 Administrator for the Account.  Upon designation of new Administrator by
                 Account Holder, Administrator shall transfer the Account to such new
                 Administrator within ten (10) days of such designation.  If Account Holder
                 fails to elect either option (i.) or (ii.) above within the above thirty (30) day
                 period, or the new Administrator designated by Account Holder fails to accept
                 the transferred Account within ten (10) days of such designation,
         B.   Administrator may at it's discretion close the account and distribute to
                Account Holder funds remaining in the Account on the date the Account is
                closed less any administrative fees due Administrator and any withdrawal
                penalties required under the Act.  In the event Administrator terminates this
                Agreement pursuant to this paragraph, Administrator shall not be liable in
                any way to Account Holder for any penalties or taxes incurred by closing or
                transfer of the account.
         C.   Account Holder may terminate this agreement at any time upon written
                notice to Administrator instructing Administrator to close the Account or
                transfer the Account to a new Administrator.  If account holder fails to
                designate a new Administrator or a new Administrator fails to accept the
                transferred Account within (10) days of such designation, Administrator
                may (at its discretion ) close the Account and distribute to Account Holder the
                funds remaining in the account less any administrative fees due Administrator
                and any withdrawal penalties required under the Act.  In the event Account
                Holder terminates this Agreement pursuant to this paragraph, Administrator
                shall not be liable in any way to Account holder for any penalties or taxes
                incurred by closing or transfer of the Account.
 
IV.   MISCELLANEOUS
 
                This agreement shall be governed by the laws of the I.R,S. and the State of Utah.
                This Agreement shall be binding upon the parties hereto and inure to the benefit of
                the parties,  their respective successors and assignees.  This Agreement sets forth
                the entire Agreement of the parties, covering all matters agreed upon or understood
                in the transaction contemplated hereby.  If any part of this agreement is deemed to
                be unenforceable, the balance of the Agreement shall remain in full force and effect.
                The Waiver by either party of a breach of any provision of this Agreement shall not
                operate as or be construed to be a waiver of any subsequent breach thereof.  No
                amendment to this Agreement may be made except in writing signed by al parties.
                Any dispute arising between the parties under this Agreement shall be settled by
                arbitration in accordance within the rules of the American Arbitration Association.
                The parties agree that a party defaulting in any way hereunder shall be obligated to
                enforce its rights hereunder, including reasonable attorneys' fees whether such
                enforcement is by arbitration, suit, or otherwise.  This agreement shall become
                effective only upon acceptance by Administrator.
 
ADMINISTRATOR:
HSA ADMINISTRATORS                                    ACCOUNT HOLDER:
OF UTAH INC.                                                     _________________________________
 
BY___________________________                SOC. SEC # _________________

ITS__________________________                  DATE:             /               / 20
 
HAS ACCOUNT HOLDER HAD HEALTH INSURANCE IN THE LAST SIX (6)
MONTHS?            [  ] YES                    [   ] NO
 
ALL ACCOUNT HOLDER INFORMATION WILL BE HELD ON A NEED TO KNOW BASIS WITH THE FOLLOWING PASS WORD OR NUMBER
REQUIRED_____________________________________________.