Last Updated 11/11/2020. $ C. Amount your employer will. 800-791-9361. Your employer must notify you and the trustee of your HSA that the contribution is for 2020. 3 0 obj payroll deduction forms for employees Questions? responsibility to determine if I am eligible to make contributions to an HSA. Payroll Deduction Authorization for Health Savings Accounts (HSAs) Here’s how those numbers break down by different pay periods: 111907 only HSA eligible for a portion of that year, you must remain HSA eligible through the end of the next tax year or face tax penalties. Employees that are age 55 and older may contribute an additional $1,000 as an HSA catch-up contribution. <> I wish to: Begin a deduction Change my deduction Stop my deduction Effective date_____ <> If you choose this approach, you can deduct your HSA contribution amount on your tax return. 2021. 2. © 2012-2021 University of Tennessee at Chattanooga. x��=ko#G������� u6��z��.k�c�$Y\�fw�8,��A#�Ė=2���G�]����V˸5`��fY$�E�^oΗ����t�|����z2��]'?��Z����d}��������G��&׳��Y���"����>˚'���W��u2�����Wo��,�����W��%"/2�*���>��� 2021 Payroll Deduction Authorization for Health Savings Account (HSA) You have enrolled in an OEBB HSA qualifying plan and are eligible for a HSA payroll deduction. Maximum HSA contribution. Optum Bank. %PDF-1.5 endstream endobj startxref By opening a health savings account (HSA) with HealthEquity, you accept the terms of HSA enrollment and the custodial agreement. Deduction to Health Savings Account Return this form to AD 165 or e-mail completed form to [email protected]. This form must be returned to the Payroll and Employee Benefits Office at least 10 business days prior to pay distribution date to process HSA deduction. If yes, write $1,000. ... 2021 annual HSA contributions Coverage type: Total annual contribution * Per month Self-only: $3,600 $300: Family $7,200: $600 * 2021 Payroll Deduction Form for HSA Contribution Use this form to indicate the amount of your payroll contributions to be placed in your Health Savings Account (HSA). Section 2: Calculate Your Maximum HSA Contribution Use the worksheet below to determine how much you can contribute to your HSA in 2021 Select your enrollment status Individual HSA Family HSA A. Complete all entries on this Enrollment Form. h�bbd```b``���2 �A,rDr����H�`2!¥"�o����5�lV0�lB1XM8�T�� �o�H�-`v��l)�f�m�f����D*��m���A RRH2*�E���CA$X�1���������}���v'P�%�30��` ��& PAYROLL DEDUCTION FORM Return this form to: HR Benefits Email: [email protected] HSA Payroll Deduction Form 2020-2021 Email completed form to: [email protected] Or send to: SPUSD Attn: Business Services - Benefits 201 S. Steckel Dr, Santa Paula, CA 93060 Employee Information Employee Name Maximum Total Annual HSA Contribution Limit Per IRS Coverage Level Maximum Annual Contribution* 10thly 12thly Coverage Level Maximum $1,000 $1,000 Contributions: ** Calendar Year 2021 ���IQ�LȄ�*� TF�N��yHQM�p��Y�%��YUt�}��|��֣�t�Fi9Z�c9����h���^��� ��:�8�D&���c$��s�ͩ����2��du��dx�j) Your kU�T1�P|P�8�EU�-��Ī��B}D5[��b��%)c��bt�����:��RKԯ�l����Z+�I��J %7_����=u�dB�`Y*��. endobj PLEASE USE THIS FORM TO START OR CHANGE YOUR HSA DEDUCTION Contribution Criteria. ua`��Q�� Last name Employee # Your Health Saving Account belongs to you and is your financial asset even if you change employers. 2021 Single Maximum Contribution Allowed: $3,600.00* 2021 Family Maximum Contribution Allowed: $7,200.00* Employer contributes $1,250.00 annually Employer contributes $2,100.00 annually *For age 55 or over, an additional $1,000.00 catchup contribution is available <>/ExtGState<>/ProcSet[/PDF/Text/ImageB/ImageC/ImageI] >>/MediaBox[ 0 0 612 792] /Contents 4 0 R/Group<>/Tabs/S/StructParents 0>> 1 0 obj 373 0 obj <> endobj Your Health Savings Account belongs to you and is your financial asset even if you change employers or health plans. Family HSA A. … Plan Contact Information. Yes, write $1,000 C. How much your employer will contribute in 2021 D. A + B – C = The most … For 2021, employees may contribute up to an IRS maximum of $3,600 for self only coverage or $7,200 for family coverage. This form is usually created after the tax filing deadline (typically April 15th) to include any contributions made to your HSA up to the tax filing deadline. Maximum Catch-Up . ... 2021 Annual Contribution Limit $3,600.00 $4,600.00 $7,200.00 ... Microsoft Word - 2015 HSA payroll deduction auth form with edits.docx Single CoverageIRS Family Coverage. Please complete the following: FIRST NAME M.I. �Ln�[e�}���O�$�Gr��ׯ�A�y�j?j J��x�$o>`���2ɟI8O��.�t�U�n"7L% � Changes are effective the first payroll of the month. Are you age 55 or older? The contribution will be reported on your 2021 Form W-2, Wage and Tax Statement. Family HSA A. FREE 14+ Sample Payrolle Deduction Forms in PDF Excel Word. Employee <>>> AUTHORIZATION. payroll deduction to the health savings bank account I maintain in connection with the HSA program. Confirm your deferral on your paycheck. You ... Employee_HSA_payroll_deduction_form_20200901. This authorization will CONTRIBUTION AMOUNTS. Employees enrolled in one of the College’s qualified high deductible (HSA) medical plans may contribute to a health savings account through payroll deduction. ` 7~T 4 0 obj Breakdown of the Health Savings Account contributions: FAMILY SINGLE IRS Maximum Contribution for 2021 $7,200 $3,600 Employee Maximum Contribution $5,200 $2,600 Plan Deductible $4,000 $2,000 Health Savings Account Enrollment Form . allowed for 2021: $ B. Employee HSA payroll deduction form. 458 0 obj <>stream $ E. A + B - C - D = $ This is the most you can contribute in 2021. employee id number (ein) social security number (required) birth date female male single married street city zip county home phone cell phone email maximum hsa contribution H.S.A. Forward completed form to your Payroll Specialist or [email protected]. By May 31, you should receive a Form 5498-SA from your HSA custodian, reporting the total contributions made to your HSA for the 2020 tax year. ____ Change Payroll Deduction Amount ____ Stop Payroll Deduction Amount of Payroll Deduction: $_____ ____ Per Bi-Weekly Pay Period ____ One Time Deduction ____ I do not wish to contribute to my Health Savings Account at this time. You must be enrolled in a consumer-driven health plan (CDHP) with a HSA before you can start a payroll deduction. Education Details: A payroll deduction form is a type of form where a certain percentage of salary amounts get deducted on various allowances like medical, traveling, provident fund etc.The form is used by the employers for the employees in the respect of deducting certain cost in the term of service. You get the tax deduction for HSA contributions made by anyone except your employer, but you are responsible for FICA tax. Please print. 0 Instead of a year long payroll deduction you also have the option to "front load" your HSA account and then stop deductions after you reach the IRS max. Completion of this form authorizes the State of South Dakota to make a payroll deduction and transfer the funds into your Health Savings Account at Discovery Benefits. Change my HSA Contribution to $ per payroll to be effective on . If no, write $0. 2021 HSA Election Form Please complete the following: First Name M.I. %PDF-1.7 %���� h�b``�b``�����ಗA��b�,&:700l=��t�i8,b�������,����@uLJ` R�a6�Mn�������EBw3)9�(�D0�/�jaX�`�`� j��A�Cx �gV�&�N^`�Q�Ġ�x��� ����c� *Y�b �M���/`��Ű�!���A\A���-���3$5�9(&H`�`��������!�A����� ����n�@q��L�t�] z� �XO0�`��Z�0h���� The limit for your 2021 contributions is $3100 self, $6200 family (increase by $1000 if you are age 55+). 414 0 obj <>/Filter/FlateDecode/ID[<101C6D44FDAD2840AF62C3AFE0E8CD82><72650D0B6BA65149A13BCC7C901D2315>]/Index[373 86]/Info 372 0 R/Length 165/Prev 226668/Root 374 0 R/Size 459/Type/XRef/W[1 3 1]>>stream This is the most you can contribute in 2021. If yes, write $1,000. PAYROLL DEDUCTION . endstream endobj 374 0 obj <>/Metadata 66 0 R/Names 416 0 R/OpenAction 375 0 R/Outlines 84 0 R/PageLayout/SinglePage/Pages 371 0 R/StructTreeRoot 90 0 R/Type/Catalog/ViewerPreferences<>>> endobj 375 0 obj <> endobj 376 0 obj <. Health Savings Account Payroll Deduction 2021 . Calendar Year 2021 $3,60 0$7,20. ©ConnectYourCare Form 400001 00082016. �=l��a���{�g nb[f�`���ʎ�Y��fa`�z If you don’t contribute through pre-tax payroll withholding, you can also make tax-deductible contributions to your HSA. 2021 annual HSA contributions Coverage type Total annual contribution Per month Self-only $3,600 $300.00 Family $7,200 $600.00 * Total annual contribution-(MINUS) Total annual employer contribution = Total eligible amount Total eligible amount / (DIVIDED) Enter number of pay periods remaining in the year from form submittal date = Per-pay period max withholding Calendar Year 2021 $3,60 0$7,20 ... Health Savings Account are eligible expenses with substantiated receipts. %%EOF 3. CONTRIBUTION FORM . 2021 HSA Payroll Election Form. endobj Return completed forms to: Company name: Attn: Fax: Email address: Employee_HSA_payroll_deduction_form_20190619. (ex: elect four (4), $837 deductions during the beginning of the year and then stop the deduction.) a.Internal Revenue Service (IRS) 2021 Contributions Limits $ 3,600 $ 7,200 $ 7,200 b.City of Wisconsin Rapids 2021 HSA Contributions 375 750 750 c. Maximum 2021 Employee HSA Contribution Amount $ 3,225 $ 6,450 $ 6,450 d. Additional “Catch-Up” contribution (maximum $1,000) You are eligible to make an additional “catch- %���� If yes, write $125. Employees may actually contribute more money into their HSA than just the amount of the deductible. Annual Limits . HSA PAYROLL DEDUCTION FORM . 2021 coverage $7,2 A available to me under the plan and that the above deductions, if any, will be made on a pre basis. Maximum HSA contribution. If yes, write $125. … (Maximum annual HSA contributions for 2020 are $3,550 for single and $7,100 for family; 2021 maximum annual HSA contributions are $3,600 for single and $7,200 for family.) Follow these easy steps: 1. All rights reserved. Please Note: Beginning January 1, 2021, the state will no longer monitor employees' HSA contributions. Your contributions to the health savings account will be made pre-tax through payroll deductions. put in your HSA in 2021: $ D. Will you qualify for the SmartHealth wellness incentive in January 2021? $ C. Amount your employer will. This is the IRS limit, minus the University’s maximum contribution of $500 single/$1000 family. If no, write $0. Keep a copy for your records. Maximum amount that can be put in your HSA for 2021 $3,600 $7,200 B.Are you age 55 or older? allowed for 2021: $ B. If no, write $0. Directions: Use the “TAB” key to move through this form. Sign and date this form. put in your HSA in 2021: $ D. Will you qualify for the SmartHealth wellness incentive in January 2021? $ 250- $ 500- stream Your employer can make contributions to your HSA from January 1, 2021, through April 15, 2021, that are allocated to 2020. Are you age 55 or older? $ E. A + B - C - D = $ This is the most you can contribute in 2021. Health savings account (HSA) contribution limits for 2021 are going up $50 for self-only and $100 for family coverage, the IRS said on May 21, giving employers that … Replace Existing Deduction Cancel Payroll Deduction. Employee Signature Date HSA Bank Payroll Deduction Form 2021 This is the most you can contribute in 2021. I wish my contributions to begin on pay date: Per paycheck Amount: #of paychecks: Annual Contribution Amount: ANNUA L LI M ITS. No, write $0. endobj 2021 hsa payroll deduction authorization member information last name first name m.i. 2 0 obj LAST NAME SOCIAL SECURITY NUMBER . 2021 annual HSA contributions Coverage type Total annual contribution Per month Self-only $3,600 $300.00 Family $7,200 $600.00 * Total annual contribution-(MINUS) Total annual employer contribution = Total eligible amount Total eligible amount / (DIVIDED) Enter number of pay periods remaining in the year from form submittal date = If no, write $0. If you are not HSA-eligible for the full calendar year, prorate your annual contribution limit based on the number of full months you are HSA-eligible. Smarthealth wellness incentive in January 2021 name first name m.i through this form - -... Form please complete the following: first name m.i tax deduction for HSA contributions made by anyone your! To hrservicecenter @ memphis.edu AD 165 or e-mail completed form to hrservicecenter @.! 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