2021 Payroll Deduction Form for HSA Contribution
Use this form to indicate the amount of your payroll contributions to be placed in your Health Savings Account (HSA).
Please complete the following:
Your Health Savings Account belongs to you and is your financial asset even if you change employers or health plans. Your
contributions to the health savings account will be made pre-tax through payroll deductions.
The maximum combined employee/employer contribution amount cannot exceed the IRS stated maximums of $3,600 for
individual coverage and $7,200 for family coverage for the 2021 calendar year. Individuals age 55 and older can make an
additional $1,000 catch up contribution. Check the IRS guidelines for maximum contributions at www.treas.gov and click on Health
Savings Accounts.
Please indicate the type of contribution you wish to make:
New Recurring Contribution
I would like to begin contributing the following amount to my HSA through pre-tax payroll deductions:
$ ____________________________ per plan year or $_________________________ per pay period. I understand
that the elected amount will be deducted from my pay unless I make changes.
Central Bank Health Savings Account Number: __________________________
Central Bank Health Savings Account Routing Number: _____________________
Name(s) on Account: __________________________________________________________
Change Recurring Contribution
I would like to change my recurring contributions to my HSA to the following amount through pre-tax payroll deductions:
$ ____________________________ per plan year or $_________________________ per pay period. I understand
that the elected amount will be deducted from my pay unless I make changes.
One-Time Contribution Change
I would like to make a one-time contribution to my HSA for the following amount through a pre-tax payroll deduction:
$____________________________ as a one-time change to my contributions.
I agree to the above payroll deduction request and will submit this form to my Employer for processing.
• I authorize my employer to reduce my pay before taxes on a "per pay period" basis as indicated above.
• I understand my payroll contribution election is for one HSA plan year and that I can add, change or revoke my HSA
contribution at will in accordance with the Plan's HSA rules.
• I understand that my election contributions and changes must comply with federal regulations and the Internal Revenue
Code (IRC) rules.
• I understand that the date of my payroll may differ from the date the funds are actually deposited and are available for use.
• I certify that I am eligible to make HSA contributions and I understand my Employer will rely on this certification in making
the contributions to my HSA and for appropriate tax withholding and reporting.
• I understand it is my responsibility to watch the deductions on my paycheck to ensure this change has taken place.
Print Name __________________________________________ Payroll Effective Date: _______________________
Signature ___________________________________________ Signature Date: ____________________________
Return this completed form to Human Resources.
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