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Fulton County Government Authorization for
Payroll Deduction/Health Savings Account Contribution
This form is for you to authorize your employer to deduct money from your paychecks throughout 2021 and deposit it
into your Health Savings Account (HSA) on a pre-tax basis. To begin payroll deductions, you must be enrolled in
the Anthem HSA Plan. If you are enrolled in the Anthem HMO Plan, the Anthem POS Plan, or the Kaiser HMO
Plan, you cannot contribute to this account. HSA payroll deductions continue through December 31, 2021. To make
HSA contributions for the following plan year, you must make a new election. Money from your pay is deposited into your
HSA account at Anthem Act Wise after each payroll run. Return this form to employeebenefits@fultoncountyga.gov
by the appropriate deadline. Please keep a copy for your records.
Effective date: _________________________ (your payroll office can confirm the effective date)
Section 1: Employee Information
Name (last, first, middle initial): ______________________________
Phone number: __________________
Mailing address: _________________________________________ Date of birth: ___________________
Email address: __________________________________________ Age: __________________________
Employee ID: ___________________________________________
Section 2: 2021 Contributions to Your HSA
Maximum employee contribution* $2,850
$5,700
IRS maximum (employer + employee contributions)*
*If you are age 55 or older in 2021, you can mak e an additional “catch-up” annual contribution of $1,000. For example, if
you are age 55 or older, the individual annual maximum contribution would be $4,600. Your employer will contribute
$750. This means you may request up to $3,850 in payroll deductions for the year.
Section 3: How Your Employee HSA Contribution Will Be Calculated
I elect to contribute $_____________ annually t o my Health Savings Account. This request replaces any previous
payroll deduction requests for my HSA. Write in the total annual contribution you want withheld from your
paycheck for 2021. The per-paycheck amount will be determined by the Benefits Office by dividing the annual
amount by 24 pay periods (or, for mid-year enrollments, dividing by the number of pay periods remaining in
the year). Please note: You risk paying IRS penalties if you exceed the allowed annual contribution. If this is a
mid-year change, be sure to consider any amounts you have already contributed.
Section 4: Employee’s Signature (Required)
By signing this form, I am requesting that payroll deductions be started or changed as shown above in Section 3, and I
agree to the preceding terms. I understand that, per IRS rules, there are maximum HSA employee contribution limits,
and I may be liable for tax penalties if I exceed this amount.
Employee’s signature: _______________________________________ Date: ________________________________
Annual contribution: $______________
(must match amount in Section 3)
Remaining 2021 paychecks: ________
Per-paycheck contribution: $________
HSA (09/2020)
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signature
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