Health Savings Account Change Form - Archdiocese Of St Paul And Minneapolis

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A
S
P
M
RCHDIOCESE OF
T
AUL AND
INNEAPOLIS
H
S
A
CHANGE F
EALTH
AVINGS
CCOUNT
ORM
: __________________________
P
Y
: January 01 - December 31, 2017
E
D
LAN
EAR
FFECTIVE
ATE
PARISH / SCHOOL / LOCATION NUMBER: ______________
PARISH/SCHOOL/LOCATION NAME: ________________________ CITY: _________________
E
I
:
MPLOYEE
NFORMATION
Name:
Last 4 digits SSN:
Address:
City:
State:
Zip:
Primary Phone: (
)
-
Work Phone: (
)
-
Email Address***:
Health Savings Account*
Total Plan Year Election (change HSA annual election to) $
** (
__________
amount/pay period) $
PLEASE NOTE: Bi-Weekly paid employees will only have an HSA deduction take out 2 times per month (total of 24 in a plan year)
Waive Coverage (I no longer want to contribute or no qualify for the HSA contribution)
Benefit Card*** REQUIRED Email Address: _______________________________________________
*To be eligible you cannot also be enrolled in another health plan that would disqualify an HSA contribution.
**Cannot exceed the IRS maximum per calendar year for 2017 of $3,400 for those electing single health insurance or $6,750 for those
electing family health insurance.
***I understand that I am required to update OneDigital with my email address for purposes of maintaining an HSA account.
E
A
:
NROLLMENT
UTHORIZATION
I understand the benefit options and requirements presented therein. I making a change as I indicated in the above section and I authorize reductions from
my earnings. I agree to observe the terms and conditions of the HSA Plan and all rules and regulations established by the Company to administer the Plan. I
understand that the Employer cannot be held responsible for the tax consequences which may or may not result from the benefit(s) I have selected above.
This plan is regulated by Internal Revenue Code Sections 105, 125, and 129, and is subject to discrimination regulations. In the event that the plan is found to
be out of compliance with discrimination rules, I may be required to reduce or eliminate my pre-tax deduction election.
E
S
:__________________________________
D
:__________________________
MPLOYEE
IGNATURE
ATE
OneDigital
2860 Vicksburg Lane N
Plymouth, MN 55447
Phone: (952) 873-7123
Fax: (866) 557-4197
For office use only:
Processed Date:____________
Processed By:_______
Employer Copy: ______
(07/2017)

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