San Juan County Employee Health Savings Account (HSA) Contribution Form
Please fill out this form out and return it to Payroll. If you are in the Sheriff’s Guild, or Medicare
eligible, please complete a VEBA enrollment form instead.
Name __________________________________________________________________
First:
Middle
Last
Current Mailing Address: _________________________________________________
Social Security Number: _______________________________
How much would you like to contribute to your HSA each month?
$
Contribution amounts may be changed quarterly. New contribution forms must be received by the 15 th of
January, April, July, or October of each year. (Not sure how much you can contribute to your HSA? Use the
information below.)
Cancel Contributions. I wish to discontinue payroll contributions to my HSA.
By signing this form I authorize my employer to reduce my pay on a per pay period basis as indicated above. I
am aware that my Social Security and federal unemployment benefits may be reduced because of my reduced
salary for tax purposes. I authorize the release of any information necessary for contributions to my HSA.
Signature _______________________________________________ Date __________________
2015 Annual HSA Contributions
Coverage Type
Single
Single age 55+*
Family
Family age 55+*
2015 Maximum
County
Max Employee
Allowed
Contribution
Contribution
$3,350
$1,500
$1,850
$4,350
$1,500
$2,850
$6,650
$3,000
$3,650
$7,650
$3,000
$4,650
*Catch-up contribution (age 55 +) is $1,000
Your eligibility to contribute to an HSA is determined by the effective date of your High Deductible Health Plan
(HDHP) coverage. Your annual contribution depends on your HDHP coverage. If you are covered on December
1 of this year, you are treated as an eligible individual for the entire year and do not need to prorate
contributions based on number of months enrolled. However – if you cease to be an eligible individual during
the plan year, the excess over the prorated contribution during the plan year is included in income and subject
to a 20% additional tax. The amount you can contribute is not determined by the date you establish your
account.
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Penalties for Nonqualified Expenses
Those under age 65 (unless totally and permanently disabled) who use HSA funds for
nonqualified medical expenses face a penalty of 20 percent of the funds used for such
expenses. Funds spent for nonqualified purposes are also subject to income tax.
Coverage of Adult Children
While the Patient Protection and Affordable Care Act allows parents to add their adult
children (up to age 26) to their health plans, the IRS has not changed its definition of a
dependent for health savings accounts. This means that an employee whose 24-year-old
child is covered on his HSA-qualified high-deductible health plan is not eligible to use HSA
funds to pay that child’s medical bills.
If account holders can't claim a child as a dependent on their tax returns, then they can't
spend HSA dollars on services provided to that child. According to the IRS definition, a
dependent is a qualifying child (daughter, son, stepchild, sibling or stepsibling, or any
descendant of these) who:

Has the same principal place of abode as the covered employee for more than onehalf of the taxable year.

Has not provided more than one-half of his or her own support during the taxable
year.

Is not yet 19 (or, if a student, not yet 24) at the end of the tax year or is permanently
and totally disabled.
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