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HEALTH SAVINGS ACCOUNT (HSA)PAYROLL DEDUCTIONEmployee Name? ? ?I, , allow Family & Children’s Center to make the following deduction from my paycheck and have this deduction be a contribution to my HSA.The limits for 2021 are:$2,700 for single coverage$5,400 for family coverageCatch up contribution $1000 (age 55 or older)Contribution per pay period:? Single coverage Family coverage Catch up contributionThis amount will be deducted based on 24 pay periods or until you elect to change and/or end employment.? This amount will be sent to your HSA at Merchants Bank and be deposited on pay day.? ?CANCEL CONTRIBUTIONEffective DateSignatureDatePayroll Processed 1/6/21 md ................
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