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Brooklyn, NY 11201
Tel.: 718 - 522-9073
NORTH MIAMI BEACH
3909 N.E. 163rd Street
North Miami Beach, FL 33160
Tel.: 786-279-1740
MIDTOWN MANHATTAN
1293 Broadway/One Herald Center
New York, NY 10001
Tel.: 212-672-6450
HEALTH SAVINGS ACCOUNT (HSA) ENROLLMENT FORM
SEPTEMBER 1, 2018 - DECEMBER 31, 2018
ASA College Human Resources Oce
_______________________________________
________________
Received Date HR Assistant Name and Title
________________________________
HR Assistant Signature
EMPLOYEE INFORMATION
Name (Last, First):
Mailing Address:
Employee ID:
Date of Hire:
City:
SSN#:
E-mail address:
Date of Birth:
Job Title:
State: Zip Code:
Phone (Daytime / Cell):
Form of Identication:
Driver’s License
State ID
Passport ID
License / ID #:
Citizenship Status:
U.S. Citizen Resident Alien Non-Resident Alien
If not a U.S. citizen, enter country of residence:
HSA ELECTION INFORMATION
Per Pay Period: Number of Pay Periods: Annual Election:
AUTHORIZATION AND ACKNOWLEDGEMENT
The annual maximum is the applicable statutory maximum for my High-Deductible Health Plan (HDHP) coverage type (i.e., single or family).
The IRS may adjust this amount each year. Contributions are prorated based on the number of pay periods you will be covered under an
HDHP. An exception to this rule allows participants with an HSA who are covered on December 1 to contribute the entire amount for the
year. Your HSA contribution election can be changed prospectively, for any reason in accordance with the administrative provisions set forth
by Human Resources.
By electing HSA benets, I am certifying that I meet the requirements under Internal Revenue Code § 223 to be eligible to contribute to an
HSA. I understand that:
• I must be covered by an IRS qualied HDHP to contribute to an HSA.
• I may not be claimed as a dependent on another individual’s income tax return.
• I may not be covered by other medical coverage, including Medicare or my spouse’s Medical Flexible Spending Account.
• HSA benets cannot be elected in addition to a Medical Flexible Spending Account reimbursements unless a Limited Purpose Medical
Flexible Spending Account is available.
• For more information about HSA eligibility requirements, see IRS Publication 969.
Please return this form to your employer.
Employee Signature: Date:
2018 HSA ELECTION MAXIMUMS
• HDHP Single Coverage - $3,450
• HDHP Family Coverage - $6,900
• Additional “catch-up” allowed for those 55 years of age or older - $1,000
$ $
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