Employee Authorization For Payroll Deduction To Health Savings Account

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Employee Authorization for Payroll Deduction to Health Savings Account
Use this form to have your employer withhold money from your paychecks and deposit it into your health savings
account (HSA) on a pre-tax basis. You must be enrolled in a consumer-driven health plan (CDHP) with a HSA before you
can start a payroll deduction.
I wish to:
Begin a deduction
Change my deduction
Stop my deduction Effective date______________
Your payroll office can confirm the effective date.
Section 1: Employee Information
Name___________________________________________
SSN or employee ID _______________
(Last, First, Middle initial)
Work phone number________________
Mailing address___________________________________
Agency name_____________________
City/State/ZIP_____________________________________
Section 2: Calculate Your Maximum HSA Contribution
Use the worksheet below to determine how much you can contribute to your HSA in 2016.
Select your enrollment status
Individual HSA
Family HSA
A. Maximum amount that can be put in your HSA for 2016
$3,350
$6,750
B. Are you age 55 or older? No, write $0. Yes, write $1,000
C. How much your employer will contribute in 2016
$100.00
D. A + B – C =
The most you can contribute in 2016
If your contributions exceed the amount in D, you risk paying IRS tax penalties. If you are submitting a midyear change, be
sure to include any amounts you have already contributed in 2016.
Section 3: Calculate Your Per-Paycheck HSA Contribution
Continue the worksheet to determine how much you will contribute to your HSA per paycheck.
Individual HSA
Family HSA
Total from D. $__________
Total from D. $___________
E. Number of paychecks you will receive in 2016 __________
E. Number of paychecks you will receive in 2016 ________
F. D ÷ E =
F. D ÷ E =
This is the most you can contribute per paycheck $
This is the most you can contribute per paycheck $ _______
Amount you elect to contribute to
Amount you elect to contribute to
your HSA per paycheck
your HSA per paycheck
Can be any amount up to or less than F $__________
Can be any amount up to or less than F $___________
Employee’s Signature Required
By signing this form, I am requesting that payroll deductions be started or changed as shown in Section 3 above and agree to
the preceding terms. I understand there are maximum limits I can contribute to my HSA per IRS rules and I may be liable for
tax penalties if I exceed this amount.
This request replaces any previous payroll deduction requests for my HSA.
Employee’s signature
Date
Benefits Office Use
Employee’s annual contribution
Number of paychecks remaining for
Employee’s contribution per
2015
paycheck
(amount in Section 3 must must)
$
$
$
Return this form to your personnel, payroll, or benefits office. Keep a copy for your records.

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