Microsoft Word - 2012 Payroll Deduction Authorization form
2014 Payroll Deduction Authorization for Health Savings Account You may have your employer deduct your HSA contribution from your pay. Before deciding on the amount to be withheld each pay period: ? Review the annual contribution limits that fit your insurance coverage (Single or Family). The 2014 tax year limits are as follows: Single coverage - $3,300 including any employer contribution. Family Coverage (2 or more people on your policy) - $6,550 including any employer contribution. If you are age 55 or older at any time during the tax year, add $1,000 to the numbers above. Subtract any employer contributions from your annual limits above. (Example: Your annual limit is $3,300; your employer contribution is $500; you may contribute up to $2,850 through payroll deductions.) ? If you are not covered by a high deductible health plan (HDHP) for the full calendar year (January 1 through December 31), prorate your annual limit based on the number of full months you will be covered by the HDHP. ? Review HSA Eligibility Requirements: If you do not meet all of the following eligibility requirements, federal regulations prohibit you from opening an HSA: Covered under a qualified high deductible health plan on the first day of the month. Not covered by any other health plan, including your spouse’s health insurance. Not covered by spouse’s Medical Flexible Spending Account (FSA). Not enrolled in any part of Medicare or Tricare. Have not received Veteran’s health benefits in the past 90 days. Not claimed as a dependent on another person’s tax return. I authorize my employer to deduct (amount) $ ________________ per pay period from ?? from my paycheck.Signature _____________________________________________ Print Name ___________________________________________ Employee ID ____________________________________ Date_________________________________________________ Return completed form to HR Manager/Employer. Please do not send to Health Savings Administrators. ................
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