HSA Deduction Request Form
If you are selecting a one-time payment, you MUST create a separate request to activate a deduction for pays AFTER the one-time deduction. Recurring requests will continue until a new request is received. Requests can be submitted until the Monday before pay day - anything submitted after 3:00pm Monday will be effective on the following pay.

NOTE-Please contact Compensation if you want to change your HSA banking information.

Email address *
TCAPS Employee ID# *
Your answer
Last Name *
Your answer
First Name *
Your answer
Deduction Type-Please read note above! *
Deduction Amount (leave blank if deactivating or requesting maximum)
Your answer
Effective Pay Date *
MM
/
DD
/
YYYY
A copy of your responses will be emailed to the address you provided.
Submit
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