Employee HSA payroll deducon form
Return completed forms to:
Company name:
An:
Fax:
Email address:
Employee_HSA_payroll_deducon_form_20190619
Annual employer contribuon informaon
Self-only Family Other (oponal)
For mid-year enrollees, contact your HR department for your pro-rated employer elecon amount.
Notes
HSA contribuon limits and contribuon calculator
2019 annual HSA contribuons
Coverage type Total annual contribuon
*
Per month
Self-only $3,500 $291.67
Family $7,000 $583.33
*
Catch-up contribuon (age 55+): addional $1,000/year
2020 annual HSA contribuons
Coverage type Total annual contribuon
*
Per month
Self-only $3,550 $295.83
Family $7,100 $591.67
*
Catch-up contribuon (age 55+): addional $1,000/year
Total annual contribuon
-
(MINUS)
Total annual employer contribuon
=
Total eligible amount
Total eligible amount
/
(DIVIDED)
Enter number of pay periods remaining
in the year from form submial date
=
Per-pay period max withholding
Eligibility and contribuon limits to your health savings account (HSA) are determined by the eecve date of your high-deducble health plan
(HDHP). If you’re covered as of December 1, you’re considered an eligible individual for the enre year and you’re not required to pro-rate your
contributions. If you cease to be an eligible individual during the next calendar year, any funding over the prorated amount is considered an
excess contribution and subject to a penalty and income tax.
Employee informaon and authorizaon
Employee name Last 4 of SSN or employee ID
Please withhold $
from my (weekly/bi-weekly/monthly) payroll and apply the funds to my Lakeshore Savings HSA.
Signature Date




2020 Self-Only $3,550
3550
3550
1
3,550.00
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