HSA Contribution Form
Instructions: Use this form to elect your contributions to your HSA. This may be a one-time contribution or to
set up automatic contributions to be withheld each pay.
PERSONAL INFORMATION
<Enter Name>
Employee Name:
Social Security #:
<Enter SSN>
Phone Number:
<Enter Phone>
CONTRIBUTION INFORMATION
Frequency: ☐ Per Pay (Amount: $ <Enter Amt>
☐ One-Time (Amount: $ <Enter Amt>
)
Pay Date: <Enter Date>
)
HSA ACCOUNT INFORMATION
Bank Name: <Enter Name>
Bank Routing #:
<Enter #>
HSA Account # (if available):
<Enter #>
Name on Account: <Enter Name>
Account Type:
☐ Checking ☐ Savings
SIGNATURE
By signing this document, I acknowledge that it is my responsibility (1) to determine whether I am eligible to
make contributions to my HSA and (2) to determine whether the contributions to this HSA have exceeded the
applicable maximum annual contribution limit as outlined below.
Employee Contribution Limit (2016 Tax Year)
This is the maximum contribution allowed minus the Messiah contribution.
If you are 55+, you can contribute an additional $1,000
Employee Only
$2,450
Employee+Child(ren)
$4,950
Employee+Spouse
$4,950
Family
$4,950
I authorize the above specified contribution amount to be deducted from my pay and deposited in my Health
Savings account specified above.
Employee Signature:
Document1
Date:
<Enter Date>
Revised: 06/2015