Form Dr 0810 - Employees Election Regarding Medical Savings Account Page 2
ADVERTISEMENT
1
2DR 0810 (04/26/04) WEB
COLORADO DEPARTMENT OF REVENUE
EMPLOYEES ELECTION REGARDING
MEDICAL SAVINGS ACCOUNT
See Form Below
DETACH FORM
ON THIS LINE
EMPLOYEES ELECTION REGARDING
DR 0810 (04/26/04) WEB
COLORADO DEPARTMENT OF REVENUE
MEDICAL SAVINGS ACCOUNT
Employee's Name
Employee's SSN
Employer's Name
Employer's Address
Account Administrator's Name
Account Administrator's Address
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 section 39-22-504.7, Colorado Revised Statutes; 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 cancelled 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that I understand that any amounts withdrawn from my account for any purpose other than the payment of medical expenses of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
ADVERTISEMENT
0 votes
Related Articles
Related forms
Related Categories
Parent category: Financial