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Get Form 5305-c (rev. August 2004)

2 ", CENTER SIDES. PRINTS: HEAD TO HEAD PAPER: WHITE WRITING, SUB. 20. INK: BLACK FLAT SIZE: 8" X 11" PERFORATE: NONE DO NOT PRINT DO NOT PRINT DO NOT PRINT DO NOT PRINT 5305-C (August 2004) Department of the Treasury Internal Revenue Service Name of account owner Action Date Signature O.K. to print Revised proofs requested Health Savings Custodial Account (Under section 223(a) of the Internal Revenue Code) Date of birth of account owner Do not file with the Internal Reve.

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