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Es of giving up my interest in this HSA, I have been advised to see a legal or tax professional. I hereby give the HSA holder any interest I have in the funds or property deposited in this HSA and consent to the beneficiary designation(s) indicated above. I assume full responsibility for any adverse consequences that may result. No tax or legal advice was given to me by the Custodian of my HSA. Spouse - Signature Required: 05/2012 CeB Date: Notary - Signature Required: Date: OVER 4 Signa.

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