HEALTH SAVINGS ACCOUNT EMPLOYEE CONTRIBUTION …
HEALTH SAVINGS ACCOUNT EMPLOYEE CONTRIBUTION
ELECTION FORM
(To be completed and returned to your employer)
Employer Name: ___________________________
|ACCOUNT OWNER’S NAME AND ADDRESS |
________________________________________________________________
Last Name First Name Middle Initial
_____________________________________________________________________________________
Street Address
______________________________________________________________________________________City State Zip Code
______________________________________________________________________________________
Social Security No. Daytime Phone Evening Phone
|CONTRIBUTIONS |
I wish to contribute $___________to my HSA account each pay period on a pre-tax basis.
I understand this amount will be deducted from my paycheck until I indicate otherwise.
I wish to make a single contribution of $___________to my HSA account on a pre-tax basis. I understand this will be deducted from my paycheck one time only for the tax year __________.
|SIGNATURE |
It is my responsibility 1) to determine whether I am eligible to make contributions to my HSA;
And 2) to determine whether contributions to this HSA have exceeded the applicable maximum annual contribution limit.
_______________________________________ ________________________
Account Owner Date
................
................
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