HSA Payroll Deduction Form

Use this form to authorize pre-tax deductions from your paycheck to be automatically contributed to your Health Savings Account. After completing Sections 1 and 2 make a copy for your records and submit this electronic form to HR. If you have any questions when completing this form, please contact your Human Resources Department.
Email address *
Type of Payroll Deduction *
Employee Number
Your answer
Employee's First Name *
Your answer
Last Name *
Your answer
City *
Your answer
State *
Your answer
Zip Code *
Your answer
Payroll Deduction Amount - Per Pay Period *
Your answer
2018 IRS Contribution Maximums Per Calendar Year *Jan - Dec*
$3,450 Individual Coverage
$6,900 Family Coverage
$1,000 Catch Up (Ages 55+)

*You must include all employer HSA contributions towards the annual maximum you can contribute per year.

I understand that in order for my employer to contribute to a health savings account (HSA on my behalf, I must meet all of the following HSA eligibility conditions.

1. I have self-only or family coverage under the Employer Group Health Plan, which I understand qualifies as a high deductible health plan (HDHP) under Code 223 (c)(2).
2. I cannot be claimed as another person's tax dependent.
3. I am not entitled to and receiving Medicare, Tri-Care or VA Benefits (including covered spouse).
4. I am not covered by my spouse or domestic partner's non- HDHP, general purpose flexible spending arrangement (Health FSA) or a general purpose health reimbursement arrangement (HRA).
5. I understand that contributions to my HSA cannot exceed IRS maximum contribution guidelines.

The Plan Year funs July 1 through June 30. Note that Employer Contributions are made installments.

Employee Signature** *
Your answer
Date *
MM
/
DD
/
YYYY
**By my electronic signature on this form, I certify that the information given above is true, correct and current as of the date signed.
Submit
Never submit passwords through Google Forms.
This form was created inside of Monroe Public Schools. Report Abuse - Terms of Service - Additional Terms