2018 Employee Authorization for H.S.A Payroll Deduction Form
Please use this form if you wish to have money withheld from your paycheck and deposited into your Health Savings Account (H.S.A.)
Email address *
Last Name* *
Your answer
First Name *
Your answer
Position in the district *
This helps us quickly identify which plan you are on
2018 H.S.A Contribution Limits *
Please select your level of medical coverage to help allow us to set limits on deductions.
If you are 55 or older, you can make an additional annual "catch up" contribution of $1,000 a year.
Please indicate below if you wish to apply this option
Your H.S.A Contribution
I elect to contribute the below amount per paycheck to my H.S.A. *
This request replaces any previous payroll deduction request for my H.S.A
Your answer
Effective Date *
MM
/
DD
/
YYYY
Signature
Electronic Signature *
By typing your name below and hitting the submit button, I am requesting that payroll deductions be started or changed. Furthermore, I understand that there are maximum limits I can contribute to my H.S.A per I.R.S rules and may be liable for tax penalties if I exceed this amount.
Your answer
Please contact the payroll office at extension #3243 if you need assistance completing this form. Forms must be received by the Payroll/Benefits Coordinator no later than one week prior to the payroll date in which you would like the deduction to take effect.
A copy of your responses will be emailed to the address you provided.
Submit
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