Hsa Payroll Deduction Form (Fillable)
Download a blank fillable Hsa Payroll Deduction Form (Fillable) in PDF format just by clicking the "DOWNLOAD PDF" button.
Open the file in any PDF-viewing software. Adobe Reader or any alternative for Windows or MacOS are required to access and complete fillable content.
Complete Hsa Payroll Deduction Form (Fillable) with your personal data - all interactive fields are highlighted in places where you should type, access drop-down lists or select multiple-choice options.
Some fillable PDF-files have the option of saving the completed form that contains your own data for later use or sending it out straight away.
ADVERTISEMENT
1HSA Payroll Deduction Form
Name: ________________________________________________________________________
Street Address: _________________________________________________________________
City: _____________________________State: ____________________ Zip Code: __________
Home Phone: (_____) ____________________ Work Phone: (_____) _____________________
SSN: _____________________ Date of Birth: ______________ Date of Hire: ______________
I elect an annual contribution of $________________ for calendar year 20___.*
-
Do Not include the GT seed contribution amount
-
The annual amount elected will be divided equally among your remaining payroll periods for the
calendar year. This amount should include any previous contributions for the calendar year.
The table below shows examples of the amount you would need to contribute each payroll period in order
to reach various annual contribution amounts.
Annual
Payroll Withholding
Contribution
Weekly
Bi-Weekly
Semi-Monthly
Monthly
$
500.00
$
9.62
$
19.23
$
20.83
$
41.67
$
1,000.00
$ 19.23
$
38.46
$
41.67
$
83.33
$
1,500.00
$ 28.85
$
57.69
$
62.50
$ 125.00
$
2,000.00
$ 38.46
$
76.92
$
83.33
$ 166.67
$
2,500.00
$ 48.08
$
96.15
$
104.17
$ 208.33
$
2,900.00
$ 55.77
$
111.54
$
120.83
$ 241.67
$
3,000.00
$ 57.69
$
115.38
$
125.00
$ 250.00
$
3,500.00
$ 67.31
$
134.62
$
145.83
$ 291.67
$
4,000.00
$ 76.92
$
153.85
$
166.67
$ 333.33
$
4,500.00
$ 86.54
$
173.08
$
187.50
$ 375.00
$
5,000.00
$ 96.15
$
192.31
$
208.33
$ 416.67
$
5,500.00
$ 105.77
$
211.54
$
229.17
$ 458.33
$
5,800.00
$ 111.54
$
223.08
$
241.67
$ 483.33
$
5,950.00
$ 114.42
$
228.84
$
247.91
$ 495.83
*Contributions Limits:
Your annual HSA contribution can not exceed the statutory IRS contribution
maximums. If you are age 55 or older, you can make an additional “catch-up” contribution of $1,000 in
2009 and beyond.
See Department of Treasury website for more details.
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: ________________________
Please return completed form to your payroll representative.
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 funds to another HSA, but your
employer is not required to forward payroll contributions to another HSA provider. With respect to HSAs offered
through U.S. Bank, employers may not impose conditions on the use of HSA funds, make or influence any
investment decisions with respect to funds contributed to an HSA, or receive any payment or compensation in
connection with an HSA.
ADVERTISEMENT
0 votes
Related Articles
Related forms
Related Categories
Parent category: Business