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.
TCAPS Employee ID#
Deduction Type-Please read note above!
Stop my HSA Deduction
Deduction Amount (leave blank if deactivating or requesting maximum)
Effective Pay Date
A copy of your responses will be emailed to the address you provided.
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