Fillable 2020-HSA-Deduction-Authorization-Form-Fillable - 2019 HSA Deduction Authorization Form

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2020-HSA-Deduction-Authorization-Form-Fillable - 2019 HSA Deduction Authorization Form

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EMPLOYEE AUTHORIZATION FOR DEDUCTION TO HEALTH SAVINGS ACCOUNT
YoumustbeenrolledinaHighDeductibleHealthPlanwithanHSAthroughHSABankbeforeyoucanstarta
payrolldeduction
.
Iwishto:
Beginadeduction Changemydeduction Stopmydeduction Effectivedate
Section 1: Em
p
lo
y
ee In
f
ormation
Name(L
a
s
t
,
First,Middleinitial)
:
Social Security number :
Address:
Phone Number:
( )
Sectio n 2: Calculate Your Maximum HSA Contribution
UsetheworksheetbelowtodeterminehowmuchyoucancontributetoyourHSAin2019.
Individual HS
A
Family HSA
A
Maximumamountthatcanbe
putinyourHSAfor2020:
$3,550.00
A
Maximumamountthatcanbe
putinyourHSAfor2020:
$7,100.00
B
Areyouage55orolder?
IfNO,write$0.
IfYES,write$1,000. $
B
Areyouage55orolder?
IfNO,write$0.
IfYES,write$1,000 $
C
Howmuchyouremployerwillcontribute
in2020(askHuman Resources):
$
C
Howmuchyouremployerwill
contributein2020(Human Resources):
$
D
A + B - C = $
Thisisthemost youcancontributein2020.
D
A + B - C = $
Thisisthemost youcancontributein2020.
Ifyo
urcontributionsexceedtheamountin“D”,youriskpayingIRStaxpenalties.Ifyou’resubmittingamid‐yearchange,
be
suretoincludeanyamountsyouhavealreadycontributedin2020.
Section 3: Calculate Your Per-Paycheck HSA Contribution
ContinuetheworksheettodeterminehowmuchyouwillcontributetoyourHSAperpaycheck.
Individual HSA
Family HSA
Totalfrom
D
above: $
___________
Totalfrom
D
above: $
________________
E
Numberofpaychecks
youwillreceivein2020:
E
Numberofpaychecks
youwillreceivein2020:
F
D ÷ E = $
Thisisthemost
y
oucancontribute
p
er
p
a
y
check.
F
D ÷ E = $
Thisisthemost
y
oucancontribute
p
er
p
a
y
check.
Amount you elect to
contribute to your HSA per
paycheck (canbeanyamount
uptoorlessthanF): $
Amount you elect to
contribute to your HSA per
paycheck (canbeanyamount
uptoorlessthanF): $
Section 4: Em
p
lo
y
ee’s Si
nature
Re
q
uire
d
Bysigningthisform,Iam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ifIexceedthisamount.
This request replaces an
y
previous payroll deduction requests
f
o
r
m
y
HSA.
Employee’s signature
Date
Return this form to Human Resources. Keep a copy for your records.
HR/Payroll Section
Employee’sannualcontribution Numberofpaychecksremainingfor2020
Employee’scontributionperpaycheck
(Amount in Section 3 must match)
24
24
1,500.00
3,000.00
1/1/20
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2020-HSA-Deduction-Authorization-Form-Fillable - 2019 HSA Deduction Authorization Form

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Completed 13 July 2020

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