Health Savings Account Payroll Deduction Authorization Form 2008 Calendar Year
Employee Name SSN
E-mail
Phone
Client Company
IRS Annual Limit for 2008: Single coverage = $2,900 Family coverage = $5,800
Level of Medical Coverage: ___ Single ___ Family Coverage
Contribution Details In calculating your annual contribution, be aware that your employer may be contributing funds in your behalf. These funds are applied towards the limit. Be sure that both contributions (EE and ER) do not exceed the annual limit. Indicate contribution amount to be deducted from your pay check. (ex. $1200 spread out on all paychecks OR $1200 in the next three payrolls).
I authorize Employer Solutions Group to initiate payroll deductions, and adjusting entries thereto, from my pay check, and to deposit the value of such payroll deductions to the health savings bank account I maintain in connection with the HSA program. I understand that I may revoke this authorization by giving at least ten (10) days written notice of cancellation to Employer Solutions Group at the address listed on this form, and that the revocation will not apply to transaction initiated prior to ESG’s receipt of the notice, or to adjusting entries on previous transactions. I represent that I am the owner of the account named below and that I have the legal right to provide this authorization.
________________________________________________ Signature of Employee Date Fax completed form to 801-223-9001.
For Benefit Use Only Date Entered into HRP: _________