Fillable Hsapayrollauthorizationform1617

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Hsapayrollauthorizationform1617

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Employee Authorization for Payroll Deduction
Health Savings Account (HSA)
This form is for employees who want to have money withheld from their paychecks by California Lutheran
University and deposited into their health savings account (HSA) on a pre-tax basis.
Employee Name Employe ID #
I elect to withhold:
$__________________ from my (bi-weekly/monthly) payroll and apply these funds to my HealthEquity HSA.
IRS Code Section 223
2016 HSA Employee Contribution Limits:
$3,350 – self only
$6,750 – family
*Catch up contribution $1,000 annually – 55 and older
2017 HSA Employee Contribution Limits:
$3,400 – self only
$6,750 – family
*Catch up contribution $1,000 annually – 55 and older
You may access your HSA directly with HealthEquity at: http://www.healthequity.com/
877-694-3942
Return completed forms to:
Human Resources
Attn: Roxanne Robinson-Jones
Fax: 805-493-3655
Email: rrrobins@callutheran.edu
Employee Signature Date
I elect to:
Begin my deduction
Change my deduction
Stop my deduction
Effective date: _______________
For HR Office Use:
Enrolled in FSA verified Enrolled in HSA compatible medical plan HR Recvd: _________
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Hsapayrollauthorizationform1617

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Completed 19 February 2020

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