HSA Payroll Deduction Change Request
Employee is responsible for not exceeding annual allowable IRS contribution limits. This includes combined employee and employer contributions (January through December). Click or copy and paste the following URL in a new browser window for more information about HSA annual limits.
https://americanfidelity.com/products/reimbursement-accounts/hsa/
Email address *
First Name *
Your answer
Last Name *
Your answer
Last four digits of social security number *
Your answer
Current HSA deduction amount (if unknown, type "unknown") *
Your answer
Desired HSA deduction (amount deducted each pay period) *
Your answer
Pay date new deduction amount should begin (change request must be submitted 5 business days prior to desired pay date - or change will apply to the following pay date) *
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