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HSA Payroll Deduction Form

Complete and submit form to payroll office to make changes to HSA payroll deductions.  HCA 20-0086 (10/19)

Handle: Document-111955
Owner: Carrell, Janea (User-136, 05492:EVERETT)DS
Tuesday, April 21, 2020 02:32:56 PM PDT
Friday, October 28, 2022 08:47:27 AM PDT
Modified By: Diaz, Ailienette (User-392, 08810:EVERETT)DS
Locked By:
  • 2020 School Employee Authorization for
Payroll Deduction to Health Savings AccountUse this form to have your SEBB organization withhold money from your paychecks and deposit itinto your health savings account (HSA) on a pretax basis.
  • A Maximum amount you can put in your HSA for 2020: $3,550
B Are you age 55 or older? 4 Family maximum HSA contributionCalculate your maximum HSA contributionUse the worksheet below to determine how much you can contribute to your family HSA in 2020.
  • If you are
submitting a mid-year change to increase your contribution amount, be sure to include anyamounts you have already contributed in 2020.
  • If you need an accommodation...
Allowed
Adobe Portable Document Format (.pdf) - application/pdf
sebb-employee-hsa-deduction-authorization-20-0086-2020.pdf
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Appears In: Payroll
Preferred Version: HSA Payroll Deduction Form