Employee Hsa Contribution Form - Murray School District printable pdf download

Employee Hsa Contribution Form - Murray School District

Murray City School District

Employee HSA Contribution Form

Please fill out this form out and return it to the district office.

Name

First:_______________________ Middle:______________

Last:_____________________________________________

Social Security Number

: _______________________________

How much would you like to contribute to your HSA each month?

(Not sure how much you can contribute to your HSA? Use the information below.)

Waive Contributions. I do not wish to make payroll contributions to my HSA.

By signing this form I authorize my employer to reduce my pay on a per pay period basis as indicated above. I am aware

that my Social Security and federal unemployment benefits may be reduced because of my reduced salary for tax

purposes. I authorize the release of any information necessary for contributions to my HSA.

Signature

Date

______________________________

__________________

2014 Annual HSA Contributions

Coverage Type

2014 Maximum Allowed

Single

$3,300

Family

$6,550

*Catch-up contribution (age 55 +) is $1,000

Your eligibility to contribute to an HSA is determined by the effective date of your HDHP coverage. Your annual

contribution depends on your HDHP coverage. For 2007 and forward, if you are covered on December 1, you

are treated as an eligible individual for the entire year and do not need to prorate contributions based on

number of months enrolled. However – if you cease to be an eligible individual during the next calendar year,

the excess over the prorated contribution is included in income and subject to a 10 percent additional tax. The

amount you can contribute is not determined by the date you establish your account.

Payroll Withholding form HSA

Employee Hsa Contribution Form - Murray School District