HEALTH SAVINGS ACCOUNT PAYROLL DEDUCTION / CHANGE FORM
PARTICIPANT INFORMATION
ENROLLMENT OR CHANGE INFORMATION
Please select one of the following reasons for your enrollment or change:
New Hire/Newly
Eligible for Benefits
PAYROLL DEDUCTION AMOUNT
DOLLAR AMOUNT PER PAY
PERIOD*
*You must enter a dollar amount per pay period to avoid a delay in your election. If you do not
enter an annual election amount, your payroll deductions will continue until you complete a new
HSA Payroll Deduction/Change Form or until you reach the annual limit for contributions.
**In 2017, the maximum that may be contributed for an individual with self-only coverage under a
high deductible health plan is $3,400, or $6,750 for individual with family coverage under a high
deductible health plan. The maximum that can be contributed includes any contribution EMU
makes to your account (i.e., $500 contribution for those with self-only coverage under the high
deductible health plan or $1,000 for those with family coverage).
PAYROLL DEDUCTION AUTHORIZATION
By signing this deduction form, I authorize the amount per pay period shown above to be reduced
from my gross paycheck. I understand that this election will begin on the plan year effective date
shown above, or as soon as administratively practicable. I understand that my election will
continue for the remainder of the benefit year unless this election is properly amended or
terminated. My signature below also authorizes my employer to disclose information in this form
to HealthEquity or others necessary to facilitate direct deposits to my HSA account.
