HTML Preview Employee Health Payroll Deduction Form page number 1.
Employee Health Savings Account Payroll
Deduction Authorization Form
Use this form to withhold money from your semi-monthly paycheck and deposit it into your Health
Equity health savings account (HSA) on a pre-tax basis. You must be enrolled in High Deductible
Health Plan (HDHP) before you can start a payroll deduction.
I wish to:
Begin a deduction Stop my deduction Effective date ________________________
Section 1: Employee Information
Name (Last, First, Middle initial)
Last 4 digits of SS number or employee ID
Phone E-mail
Section 2: Calculate You Maximum HSA Contribution
Use the worksheet below to determine how much you can contribute to your HSA in 2016.
Individual Family
A
Maximum contribution in your HSA
for 2016:
$3,350
A
Maximum contribution in your HSA for
2016:
$6,750
B
Are you age 55 or older?
If NO, write $0.
If YES, write $1,000.
B
Are you age 55 or older?
If NO, write $0.
If YES, write $1,000.
C
How much your employer will
contribute in 2016*:
C
How much your employer will
contribute in 2016*:
D
A + B - C =
This is the most you can contribute in 2016.
D
A + B - C =
This is the most you can contribute in 2016.
*Individual will receive $250/yr and Family will receive $500/yr if you are an active employee enrolled all 12
months. Please check with your insurance representative if you have questions.
Section 3: Calculate Your Per-paycheck HSA Contribution
Continue the worksheet to determine how much you will contribute to your HSA per paycheck.
Individual Family
Total from D
Total from D
E
Number of paychecks you will
receive in 2016 (
24 for a full year
):
E
Number of paychecks you will receive
in 2016 (
24 for a full year
):
F
D ÷ E =
This is the most you can contribute per
paycheck.
F
D ÷ E =
This is the most you can contribute per
paycheck.
Amount you elect to contribute to your HSA per
paycheck (can be any amount up to or less than F):
Amount you elect to contribute to your HSA per paycheck
(can be any amount up to or less than F):
If your contributions exceed the amount in box D, you risk paying IRS tax penalties.
Section 4: Employee’s Signature
Required
By signing this form, I am requesting that payroll deductions be started or changed as shown in Section 3 above
and agree to the preceding terms. I understand there are maximum limits I can contribute to my HSA per IRS
rules and I may be liable for tax penalties if I exceed this amount.
Employee’s signature Date