HealthFirst Benefits Administration
HealthFirst Benefits Administration
Health Savings Account Annual Statement 800 Benefits Way, Suite 1000
Milwaukee, WI 53202
Account Holder Account Number Member ID Plan Year Coverage Type
Alex Chen HSA-4471-8832 HFB-NLK-477-JM 2016 Family (HDHP)
Employer HDHP Plan Name Statement Period Annual Contribution Limit
Clearwater Tech Premier HDHP — Family January 1, 2016 – December
Clearwater Tech, Inc. $6,750 (IRS Family Limit)
Coverage 31, 2016
Account Balance Summary
Amount
Beginning Balance (January 1, 2016) $0.00
+ Total Contributions $5,700.00
— Employer Contribution $1,200.00
— Employee Contribution $4,500.00
- Total Distributions (Qualified Medical) ($2,700.00)
+ Investment Earnings / Returns $0.00
Ending Balance (December 31, 2016) $3,000.00
Contribution Activity
Contribution Type Contributor Method Amount
Employer Contribution Clearwater Tech, Inc. Payroll / Direct Deposit $1,200.00
Employee Contribution Alex Chen Pre-tax Payroll Deduction $4,500.00
Total Contributions $5,700.00
Annual IRS family contribution limit for 2016: $6,750 | Remaining contribution room: $1,050 | No excess contribution reported.
Distribution Activity — Qualified Medical Expenses
QHE
Expense Category Description Amount
Code
Medical / Clinical Physician visits, specialist, labs, imaging 213(d) $1,650.00
Retail and mail-order Rx, OTC (post-CARES if
Prescription Drugs 213(d) $850.00
2020+)
Dental / Vision Preventive dental, eye exams, glasses/contacts 213(d) $200.00
Non-Qualified
None reported this period N/A $0.00
Distributions
Total Distributions $2,700.00
HealthFirst Benefits Administration (cid:127) HSA Plan Services
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This statement is for informational purposes only. Synthetic demo data — not a valid tax document.

HealthFirst Benefits Administration
HealthFirst Benefits Administration
Health Savings Account Annual Statement 800 Benefits Way, Suite 1000
Milwaukee, WI 53202
Investment Activity
Investment Component Details Return / Earnings
Account balance below investment threshold. Funds held in
HSA Investment Account $0.00
FDIC-insured deposit account.
Undeployed cash earning nominal interest (FDIC-insured up to
Cash / FDIC Deposit Included above
$250,000)
Implied Annual Return
Based on average invested balance (beg. bal. $0) N/A — first year
Rate
IRS Reporting Summary — Form 8889 Reference
Form 8889 Line Reference Description Amount
Line 2 — Total Contributions All contributions (employer + employee) $5,700.00
Line 9 — Employer Contributions Excluded from income — see Box 12 Code W on W-2 $1,200.00
Line 14a — Total Distributions Gross distributions from HSA $2,700.00
Line 15 — Qualified Medical
Distributions for qualified medical expenses (213(d)) $2,700.00
Expenses
Line 17b — Taxable Distributions Non-qualified distributions (taxable + 20% penalty) $0.00
Ending HSA Balance (Dec 31) Carry forward to next year's Form 8889, Line 1 $3,000.00
This statement is prepared for tax reporting reference purposes. The employer contribution reported on Line 9 of Form 8889 should match Box 12, Code W on
your W-2. Qualified medical expense receipts should be retained for a minimum of 7 years. HealthFirst Benefits Administration does not provide tax or legal
advice. Please consult your tax advisor for Form 8889 filing guidance.
HealthFirst Benefits Administration (cid:127) HSA Plan Services
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This statement is for informational purposes only. Synthetic demo data — not a valid tax document.
