Health Savings Account (HSA) Payroll Deduction
1. What is this form for?
Your employer is offering you the option to contribute to your HSA account pre-tax
through payroll deduction. You may also choose to contribute on your own after
your HSA account has been opened and take the deduction on your income taxes to
the extent appropriate under applicable law. Please list your contribution below.
2. Contributor Information
Print Full Name: _____________________________________________________
3. Contribution Information
I want the following amount placed in my HSA account from payroll deduction.
$ _________________________ per pay check beginning ________________(date).
I understand that I may only make changes to this deduction one time per quarter. I
also understand that is my responsibility to comply with IRS regulations regarding
I understand the eligibility requirements for the HSA deposit and state that I qualify
to make the deposit.
Signature of Employee: ______________________________ Date: _____________
Maximum Contribution 2011 = $3,050 (individual)
Catch Up Contribution 2011 = $1,000.00
Please note that contributions can be changed once per calendar
* Please return this form to Human Resources*