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.
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Type of Payroll Deduction *
Employee Number
Employee's First Name *
Last Name *
City *
State *
Zip Code *
Payroll Deduction Amount - Per Pay Period *
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** *
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.  
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