Checkbook HSA Application

Service & Pricing Overview
ReSure LLC provides a comprehensive solution to Checkbook HSA formation. We look forward to working with you and facilitating every step of the process - from custodian selection to bank account set-up and all the steps between those. As part of the formation service, each ReSure client is provided a Checkbook HSA operations and compliance session with a Self-Directed HSA expert. Standard pricing is $975, which is not inclusive of HSA custodial fees. To get started, please complete the following form.
Your Personal Information
First Name*
Last Name*
Email*
Phone*
Physical Address
Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
HSA-LLC Info Options
HSA-LLC Domicile, Name, Registered Agent, & Management
The central component of a Checkbook HSA is an HSA-LLC, a specially structured Limited Liability Company. Make the appropriate selection to either enter your HSA-LLC info or to schedule a discussion with a Checkbook HSA expert.
- I already have my HSA-LLC info. Take me to the HSA-LLC entry fields.
- I'd like to discuss HSA-LLC options with a Checkbook HSA expert. Skip the HSA-LLC fields, for now.

LLC Formation Information
LLC Formation State
LLC Name: First Choice*
LLC Name: Second Choice*
LLC Name: Third Choice*
LLC's Registered Agent Name & Address
LLC's Registered Agent Name & Address*
Commercial registered agent services are arranged by ReSure. Your HSA will be invoiced $110 for such services after your first year.
- Same as personal
- Commercial registered agent arranged by ReSure
- Other
Registered Agent's Name*
LLC's Registered Agent Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
LLC's Physical Address
LLC Physical Address*
- Same as personal
- Same as registered agent
- Other
LLC Physical Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Successor Manager - recommended, not required
Successor Manager Name
Successor Manager Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Successor Manager Email Address
Successor Manager Phone Number

Payment Authorization Form
Payment Authorization*
- By checking this box you authorize ReSure LLC to collect the fees due for Checkbook HSA formation and related services. Our standard low fee is not inclusive of HSA custodial fees. You may cancel this agreement at any time prior to initiation of services and receive a refund of half of your payment. Once services are initiated under this agreement, all fees are non-refundable. All LLC documents are delivered through secure electronic channels, but you may request physical delivery of your documents by selecting that option below.
Standard
Price:
Additional Options
- Multi-Member LLC
- Physical Delivery of Documents
Total
$0.00
Nature of Our Services to You
Terms & Acknowledgement*
- By checking this box you acknowledge and agree to the following: ReSure LLC, its management, and related companies are not acting as investment advisors, administrators, trustees, or fiduciaries to your IRA, HSA, or other account. Any information provided by ReSure LLC is not intended to be a substitute for professional advice from an accountant, attorney, or tax preparer. It is agreed that ReSure’s responsibility for damages, or claims of damage, arising from any form of action other than gross negligence, shall not exceed the total amount paid for the services invoiced. This shall be the exclusive remedy for such causes of action. Either party may bring no action, regardless of form, arising out of the services provided under this agreement, more than one year after the date of the last service provided under this agreement. Any dispute related to services provided shall be settled by arbitration in Kings County, New York according to the rules of the American Arbitration Association. Arbitration is final and binding on the parties. The parties are waiving their right to seek remedies in court, including the right to a jury trial. The laws and jurisdiction of the state of New York shall govern any and all matters related to this agreement.
Digital Signature (First and Last Name)*

Your typed name above constitutes a signature.
Date*
MM slash DD slash YYYY
Notes

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