Employee HSA Payroll Deduction Request 

Use this form to indicate the amount of your payroll contributions to be placed in your Health Savings Account (HSA). This form must be submitted by the 15th of the month in order to be effective for that month’s payroll. Return completed form to: 

South Sanpete School District, Attn: Payroll 

Fax: 435-835-2265 E-mail: This email address is being protected from spambots. You need JavaScript enabled to view it.

Print Name _____________________________________ Last 4 of Social Sec Number _________________ 

The maximum combined employee/employer contribution amount cannot exceed the IRS stated maximums of $3,550 for individual coverage and $7,100 for family coverage for the 2020 calendar year. Individuals age 55 and older can make an additional $1,000 catch up contribution. Check the IRS guidelines for maximum contributions at www.treas.gov and click on Health Savings Accounts. Employees are responsible for tracking contributions. Please indicate the type of contribution you wish to make: New Recurring Contribution 

I would like to begin contributing the following amount to my HSA through pre-tax payroll deductions: 

$________________ per pay period 

I understand that the elected amount will be deducted from my pay unless I make changes. 

Change Recurring Contribution 

I would like to change my recurring contributions to my HSA to the following amount through pre-tax payroll deductions: 

$________________ per pay period 

I understand that the elected amount will be deducted from my pay unless I make changes. 

One-Time Contribution Change 

I would like to make a one-time contribution to my HSA for the following amount through a pre-tax payroll deduction: 

$_______________ as a one-time change to my contributions 

pdfEmployee_HSA_Payroll_Deduction_Request.pdf

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