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Hsa Enrollment Form

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HSA Payroll Deduction Form

ACCOUNT HOLDER INFORMATION

Name: _________________________________ Employee ID: ______________

Street Address: ______________________________________________________

City: ___________________________ State: ____________ Zip: ____________

Date of Birth: _______________________ Date of Hire: ___________________

ELECTION & CONTRIBUTION INFORMATION

Please check the appropriate box below:

I wish to establish a new HSA with US Bank

I wish to change my current election

Individual Consumer Choice HSA Coverage

Family Consumer Choice HSA Coverage

My Annual Contribution

I am eligible to contribute an additional

$1,000 per year because I am 55 or older

Total Annual Family Contribution for 2016

Total Annual Individual Contribution for 2016

Cannot exceed $6,750 if under 55

Cannot exceed $3,350 if under 55

Cannot exceed $7,750 if over 55

Cannot exceed $4,350 if over 55

I understand that I cannot exceed the maximum annual contribution amounts per healthcare coverage

established by the IRS for a Health Savings Account as illustrated above. Changes to my contribution

amount can be made by submitting a written request to my employer.

Please forward pre-tax contributions from my paycheck to my Health Savings Account in the following

amount: $_______________ per paycheck beginning on my _____________ paycheck.

**The University System of Georgia will provide a monthly match into the account for employees with the Consumer Choice

HSA Plan. The maximum annual contribution will be decreased by the match amount listed below.

Match Amounts: Individual - $375.00

Family - $750.00

By signing this form, I authorize AU to deduct the elected amount from my pay on each pay date. I hereby consent that all

personal information and selections made are correct.

Employee Signature: _________________________________________ Date: ____________

Hsa Enrollment Form

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