Employee Authorization for Payroll Deduction
Health Savings Account (HSA)
This form is for employees who want to have money withheld from their paychecks by California Lutheran
University and deposited into their health savings account (HSA) on a pre-tax basis.
Employee Name Employe ID #
I elect to withhold:
$__________________ from my (bi-weekly/monthly) payroll and apply these funds to my PayFlex HSA.
IRS Code Section 223
2018 HSA Employee Contribution Limits:
$3,450 self only
$6,900 family
*Catch up contribution $1,000 annually 55 and older
You may access your HSA directly with PayFlex at: http://www.payflex.com/
844-729-3539
Return completed forms to:
Human Resources
Attn: Angie Guerrero
Fax: 805-493-3655
Email: aguerrero@callutheran.edu
Employee Signature Date
I elect to:
Begin my deduction
Change my deduction
Stop my deduction
Effective date: _______________
For HR Office Use:
Enrolled in FSA verified Enrolled in HSA compatible medical plan P/S updated HR Received: _________
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