Form Dr 0810 - Employees Election Regarding Medical Savings Account
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1DR 0810 (07/18/13)
*130810==19999*
COLORADO DEPARTMENT OF REVENUE
Denver, CO 80261-0005
Employees Election Regarding
Medical Savings Account
Employee's Last Name
First Name
Middle Initial SSN
SMith
Rachalee
r
394-58-6262
Employer's Name
McDonalds
Employer's Address
City
State
Zip
123 Clark St1
Commerce City
CO
80904
Account Administrator's Last Name
First Name
Middle Initial
Jones
Sandy
R
Account Administrator's Address
City
State
Zip
1234 clark st
commerce city
Co
80123
I hereby certify that I am an employee of the above listed employer who has offered to establish a medical savings
account in my name with the above listed account administrator in accordance with §39-22-504.7, C.R.S.; or that my
employer has not offered to establish such an account but I have established such an account with the above listed
account administrator.
I hereby elect to have my contributions to such account, not to exceed $3,000 in any one calendar year, whether paid
by my employer, withheld from my wages and paid to the account administrator by my employer, or paid directly to the
account administrator by myself, to be made on a Colorado pre-tax basis.
Amounts may be distributed from a medical savings account only for the purpose of: reimbursing the eligible medical
expenses of the account holder, his or her spouse or dependent children; cashing out the balance in the account of a
deceased holder; or cashing out an account holder's prior years' balance.
This election and agreement shall continue in effect until canceled by myself or by the account administrator. I hereby
acknowledge that I understand that any amounts withdrawn from my account for any purpose other than the payment of
medical expenses of myself, my spouse, or my dependent children will constitute Colorado taxable income for myself or
my estate, as the case may be.
Signature
Date
(MM/DD/YY)
11/11/11
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