Health Savings Account (Hsa) Contribution Form For State Centralized Payroll Employees
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1HA-0913-0915
STATE OF NEW JERSEY
DIVISION OF PENSIONS AND BENEFITS - STATE HEALTH BENEFITS PROGRAM
HEALTH SAVINGS ACCOUNT (HSA) CONTRIBUTION FORM
FOR STATE CENTRALIZED PAYROLL EMPLOYEES
EMPLOYEE INFORMATION
Employee Name: __________________________________________________________________________________
Last
First
Middle Initial
Social Security Number: _________________________
Payroll Number: ______________
Date:_______________
PAYROLL REQUEST
I authorize the State of New Jersey to deduct the Health Savings Account (HSA) contributions identified below on a
pre-tax basis beginning no earlier than the date my HSA medical plan will become effective. The funds are eligible to
be deposited into my Health Savings Account.
Contributions are subject to federal limits. Annual limits for 2016: $3,350 for individuals; $6,750 for families. Note:
Employer contributions to your HSA count toward the annual limit.
Additional allowable contributions for individuals between the ages of 55 - 65: $1,000 for the account holder only.
Please fill in the desired amount below.
Per Pay Period: ________________
Contributions will begin after your HSA bank account has been opened with the banking institution selected by your
provider.
Cancel deductions for the Health Savings Account from my paycheck.
HEALTH PLAN
High Deductible Health Plan (HDHP) (Choose one from below)
NJ DIRECT HD4000
Aetna Value HD4000
NJ DIRECT HD1500
Aetna Value HD1500
Coverage Level (Choose one from below)
Single
Member and Spouse/Civil Union Partner
Member and Domestic Partner
Family
Parent and Child(ren)
Employee Signature: ___________________________________________________________ Date: _______________
Please return the completed form to:
NJ Department of the Treasury
OMB — Centralized Payroll
PO Box 207
33 W. State Street, 2nd Floor
Trenton, NJ 08625
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