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ADDRESS: DATE OF BIRTH: GENDER: I acknowledge that I am qualified to and hereby make the following contribution to my Norwalk Public Schools Health Savings Account (HSA) for the January 1, 2011 to December 31, 2011 plan. I agree to have my annual, taxable, compensation reduced by an amount equal to the total value of the contributions specified below, such annual amount to be deducted in approximately equal sums from my regular paychecks during the Plan Year on a pre-tax basis.

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