Health Savings Account
You may type on this form, then print, sign, and mail Payroll Deduction
APPLICANT’S NAME SOCIAL SECURITY #.
Last First MI
COMPLETE MAILING ADDRESS (Include city, state, zip) EMAIL ADDRESS
DATE OF BIRTH DATE OF EMPLOYMENT CAMPUS PHONE HOME PHONE
Mo. Day Year Mo. Day Year
Academic (10 paycheck deductions)
I elect to have the following amount deducted per paycheck * Monthly (12 paycheck deductions)
Bi-weekly (24 paycheck deductions)
I understand this deduction will not change unless I change my election by submitting a new HSA payroll Deduction Form.
*Contributions Limits: Your annual HSA contribution cannot exceed the statutory IRS contribution maximums. If you are age 55 or older, you can
make additional “catch-up” contributions of up to $1,000.
4 See Department of Treasury Web site for more details. http://www.treas.gov/offices/public-affairs/hsa/
Below, see examples of payroll period contribution amounts in order to reach various annual contribution amounts.
Desired annual Payroll withholding
Bi-weekly Monthly Academic
$ 500.00 $ 20.83 $ 41.67 $ 50.00
$ 1,000.00 $ 41.66 $ 83.33 $ 100.00
$ 1,500.00 $ 62.50 $ 125.00 $ 150.00
$ 2,000.00 $ 83.33 $ 166.67 $ 200.00
$ 2,500.00 $ 104.16 $ 208.33 $ 250.00
Single maximum contribution level $ 3,000.00 $ 125.00 $ 250.00 $ 300.00
$ 3,500.00 $ 145.83 $ 291.67 $ 350.00
$ 4,000.00 $ 16.66 $ 333.33 $ 400.00
$ 4,500.00 $ 187.50 $ 375.00 $ 450.00
$ 5,000.00 $ 208.33 $ 416.67 $ 500.00
$ 5,500.00 $ 229.16 $ 458.33 $ 550.00
Family maximum contribution level $ 5,950.00 $ 247.91 $ 495.83 $ 595.00
By signing this form, I authorize my employer to deduct the elected amount from my pay on each pay date. I hereby consent that all personal
information and selections made are correct.
Signature Date signed
DISCLAIMER: HSAs are personal health savings vehicles rather than group employee benefits.
Although your employer has agreed to forward contributions through its payroll system to U.S. Bank, it
has not specifically endorsed U.S. Bank or any other HSA provider. You are not restricted from moving Submit this completed form to:
funds to another HSA, but your employer is not required to forward payroll contributions to another HSA Employee Benefits
provider. With respect to HSAs offered through U.S. Bank, employers may not impose conditions on the Human Resources Bldg.
use of HSA funds, make or influence any investment decisions with respect to funds contributed to an 215 S. Jackson St.
HSA, or receive any payment or compensation in connection with an HSA. Athens, GA 30602-4133
Revised February 6, 2009
Mail completed form to: UGA Human Resources, 215 S. Jackson St., Athens GA 30602