Usethisformtorequestacorrectiontoemployer-initiatedcontributionstoOptumBank,Inc.(“Bank”)healthsavingsaccounts(“HSAs").

PART1–BankContactInformation

PleasefaxthissignedandcompletedformtotheBank:

ByMail:

OptumBank

P.O.Box271629

SaltLakeCity,UT84127

ByFax:

1-866-314-9795

ATTN:Transaction Services

Questions?

Pleasecall1-866-234-8913

CustomerServiceProfessionalsareavailabletoassistyouMondaythroughFridayfrom8:00a.m. to8:00p.m.Easterntime.

PART2–RequestorandAccountHolderInformationProvidethefollowingrequestorandemployerinformation:

Employer
Name
Group ID

* RequestormustbeadulyauthorizedrepresentativeofEmployer.

Providethedetailsontheimpactedemployees(“AccountHolders”)usingthespaceprovidedbelow(thefirstentryisprovidedasanexample).Ifcorrectionsareneededformorethan five(5)accountholders,attachanadditionalspreadsheet.

SSN/Account / LastName / FirstName / ContributionDate / ContributionAmount / ContributionType
123456789 / Doe / John / 3/15/2010 / $25.00 / Employer

PART3–ProcessingOptions

Selectoneofthetwomethodslistedbelowforthereturnoffunds:

PART4–Authorization

Employer, itselforthroughitsdesignee (collectively“Employer”),acknowledgesthat:(i)HSAcontributionsaregenerally non-forfeitable [seeIRC§223(d)(1)(E)] exceptinthelimitedcircumstancesidentifiedinIRSNotice 2008-59,Q/A 23-25;(ii) thisformdoesnotconstitutelegalortaxadvice;and(iii)Bankis notrequiredto,norinapositionto,independentlydetermine whetheranAccountHolder isan HSA eligibleindividual,anAccountHolder’spersonalannualHSAcontributionmaximum,orwhatportion ofanover-contributedHSA isattributabletoandrecoupableby Employer.

Employerrepresentsandwarrantsthat: (i) eachAccountHolderiscurrentlyemployedbyEmployer;(ii)Employerhasbeendulyauthorizedbyeach AccountHolderashis/heragentwithfull power andauthoritytoadminister orotherwiseperformanyactionwithrespecttotheAccountHolder’sHSA heldbyBank,includingbutnotlimitedtothecontributioncorrectionsdirected byEmployerherein;(iii)thisinstructionismadeinaccordancewithapplicablelawsandregulations;and(iv)theinformationprovidedhereinistrueandcorrectandmayberelieduponbyBank.

EmployerherebyinstructsBanktotakewhateveractionsdeemednecessaryandappropriatebyBank toeffectuatethecontributioncorrectionsdirectedbyEmployerhereinwithrespecttotheHSAsidentified,includingbutnotlimitedtoprocessingcontributions,distributionsorelectronicfundstransferofalloranyportionoftheamountsdepositedin,orotherwiseheldbyorrelatedto,theHSAs.Employerherebyagreestoindemnify,keepindemnified, defendandholdharmlessBankanditsdirectors,officers,employees,attorneys,agents,successorsand assignsfromandagainstanyandallclaims,penalties,fines,losses,damages,actionsandcausesofaction,whichBankoritsdirectors,officers,employees, attorneys, agents, successorsandassignsatanytimemaysustainorincurthatdirectlyorindirectlyarisefrom,orinanywayareconnectedorrelatedtotheactionstakenbyBankandthedirections,instructions,andauthorizationsgivenbyEmployerherein.

The undersignedherebycertifiesthathe/shehasbeendulyauthorizedbyallnecessaryandappropriatecorporateactionto executethisformfor andonbehalf ofEmployer.

X

AuthorizedSignatureDate

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