Health Savings Account (HSA) - HSA Change Request



5898515-7620000HEALTH SAVINGS ACCOUNT (HSA) – HSA CHANGE REQUEST 2021FORM NO. X-4353 (REV. 10-20)Complete and return this form to HRService@ to elect or make changes to your pre-tax HSA contribution. Refer to the IRS Publication 969 or contact HealthEquity at 877-713-7712 for guidance on qualifying for an HSA, contributions to an HSA, distributions from an HSA and reporting HSA contributions on your tax return. You are permitted to make changes to your HSA contribution at any time. EMPLOYEE NAME FORMTEXT ?????SAP NO. FORMTEXT ?????PHONE NO. FORMTEXT ????? FORMCHECKBOX *CHANGE EXISTING HSA DEDUCTION FORMCHECKBOX NEW HSA DEDUCTION FORMCHECKBOX STOP HSA DEDUCTION FORMCHECKBOX CATCH UP CONTRIBUTION 2021 HSA Contribution LimitYou can contribute the below amounts into your HSA if you are a U.S. citizen and are enrolled in the Consumer HDHP or Enhanced HDHP through FirstEnergy. Employer contributions and HealthyLiving rewards that deposit into your HSA accumulate toward the above maximums. It is your responsibility to ensure your contributions do not exceed the annual limits. See Publication 969 or contact HealthEquity at 877-713-7712 for more information. NOTE: You are not permitted to contribute to an HSA the six months prior to enrolling in Medicare. Consumer HDHP or Enhanced HDHP Coverage Type2021 HSA Contribution Limit/Month2021 HSA Contribution Limit/YearIndividual/Single$300.00$3,600Two-Person/Family$600.00$7,200Please deduct $________________ from each future pay and apply the funds to my HealthEquity HSA.2021 HSA Catch-Up Contribution (must be 55 years of age) Employees who turn 55 or older in 2021 who are enrolled in the FirstEnergy Consumer HDHP or Enhanced HDHP may make an additional HSA Catch Up contribution up to $1,000 in 2021.Please also deduct $________________ from each future pay and apply the funds to my HealthEquity HSA.SIGNATURE/AUTHORIZATION AND AGREEMENTNOTICE TO ALL EMPLOYEES COMPLETING THIS FORM: It is fraudulent to fill out this form with information you know to be false. By signing this document, I authorize the Company to deduct from my paycheck the amount required for the coverage that I have selected. HSA contributions cannot be changed retroactively. The above changes will occur as soon as administratively possible and can be verified on future pay statements. EMPLOYEE SIGNATURE FORMTEXT ?????DATE SIGNED FORMTEXT ????? *If changing an existing HSA contribution, please complete this page to determine future allowed contributions. Double click the table below to use as calculating worksheet.Feel free to use the below worksheet to decide what to contribute to your HSA.For employees that are paid bi-weeklyFor employees that are paid weeklyPay WeekPay DatePay WeekPay Date11/08/202111/8/202121/22/202121/15/202132/5/202131/22/202142/19/202141/29/202153/5/202152/5/202163/19/202162/12/202174/2/202172/19/202184/16/202182/26/202194/30/202193/5/2021105/14/2021103/12/2021115/28/2021113/19/2021126/11/2021123/26/2021136/25/2021134/2/2021147/9/2021144/9/2021157/23/2021154/16/2021168/6/2021164/23/2021178/20/2021174/30/2021189/3/2021185/7/2021199/18/2021195/14/20212010/1/2021205/21/20212110/15/2021215/28/20212210/29/2021226/4/20212311/12/2021236/12/20212411/26/2021246/19/20212512/10/2021256/25/20212612/24/2021267/2/2021277/9/2021287/16/2021297/23/2021307/30/2021318/6/2021328/13/2021338/20/2021348/27/2021359/3/2021369/10/2021379/17/2021389/24/20213910/1/20214010/8/20214110/15/20214210/22/20214310/29/20214411/5/20214511/12/20214611/19/20214711/26/20214812/3/20214912/10/20215012/17/20215112/24/20215212/31/2021 ................
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