Hsa Contribution Payroll Deduction Form printable pdf download

HSA Contribution Payroll Deduction Form

This is the election/change form to indicate the amount of your payroll contribution to be placed in the Health Savings Account.

FIRST NAME

M.I.

LAST NAME

ID numbers

SSN

EFFECTIVE DATE ___________________________

PAY CYCLE ___Bi-Weekly ___Monthly

CONTRIBUTION

I would like to contribute the following amount to my HSA through pre-tax payroll deductions in equal installments:

-OR-

$ ___________________________ per pay period

$ ___________________________ per year

Your HSA will accumulate money through your payroll contribution to reimburse you for qualified health care expenses. Your Health

Savings Account belongs to you and is your financial asset even if you change employers or health plans. Your contributions to the

health savings account will be made pre-tax through payroll deductions by completing this form.

Reminder: To contribute to a Health Savings Account you must meet the following criteria:



You must be covered by a Qualified High Deductible Health Plan (QHDHP), and



You cannot be covered by another health plan, including Medicare (other than a QHDHP or other non-QHDHP coverage

permitted by law), and



You cannot be claimed as a dependent on another individual's tax return.

The maximum employee contribution amount cannot exceed the IRS stated maximums for the calendar year. Individuals age 55 and

older can make additional catch up contributions. Check the IRS guidelines for maximum contributions at

and click

on Health Savings Accounts.



I authorize my employer to reduce my pay before taxes on a "per pay period" basis as indicated above.



I understand my payroll contribution election (if any) is for one HSA plan year and that I can add, change or revoke my HSA

contribution at least once per month in accordance with the Plan's HSA rules.



I understand that my changes must be prospective in accordance with Internal Revenue Code (IRC) rules.



I understand that my election contributions must comply with federal regulations.



I certify that I am eligible to make HSA contributions and I understand my Employer will rely on this certification in making

the contributions to my HSA and for appropriate tax withholding and reporting.

I agree to the above deferral request and will submit this form to my Employer for processing. I also authorize my Employer to make

withdrawals from my HSA in the event that a credit entry is made in error. I understand that the custodian may provide my HSA

account number to my Employer to facilitate the money transfer. I further understand that the date of my payroll may differ from

the date the funds are actually deposited and are available for use.

Print Name _________________________________________

Date ____________________________________

Signature ___________________________________________

Return to: Missouri Western State University, Human Resources Department

Popplewell Hall 117, 4525 Downs Drive, Saint Joseph MO 64507

Original signature required; faxes and copies not accepted.

Hsa Contribution Payroll Deduction Form

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