Wells Fargo Health Savings Account Payroll Deduction Form printable pdf download

Wells Fargo Health Savings Account Payroll Deduction Form

Wells Fargo Health Savings Account

PAYROLL DEDUCTION FORM

(FORM MUST BE RETURNED TO THE BENEFITS/PAYROLL OFFICE)

Use this form to authorize deductions from your paycheck to be automatically contributed to your Health

Savings Account. After completing Sections 1 and 2 make a copy for your records and give the original form to

the Benefits/Payroll Office. If you have any questions when completing this form, please contact your

Benefits/Payroll office.

Wells Fargo H.S.A. Account Number If known

Establish Payroll Deduction for First Time

Change Payroll Deduction Amount

Stop Payroll Deduction

ACCOUNT HOLDER INFORMATION

Employee’s First Name

Last Name

Street Address or P.O.Box

City

STATE

ZIP

Phone:

E-Mail:

(

)

PAYROLL DEDUCTION

AMOUNT of DEDUCTION PER MONTH

SIGNATURE: ___________________________________________________________ DATE: ______________

ACCOUNT HOLDER: Please complete the above information and return to your EMPLOYER.

Tax Year 2016

Individual

Family

H.S.A. annual contribution limit

$3,350

$6,750

H.S.A. catch-up (must be over 55 years of age)

$1,000

NUSD-Kaiser H.S.A. annual deductible

$1,300

$2,600

NUSD-Kaiser H.S.A. maximum out-of-pocket

$3,000

$6,000

Wells Fargo Health Savings Account Payroll Deduction Form