Get Hsa Employee Contribution Election Form.doc - Concordia

Filling out the HSA Employee Contribution Election Form is a vital step for users looking to manage their health savings account contributions efficiently. This guide will provide clear, step-by-step instructions to ensure you complete the form accurately and confidently.

Follow the steps to complete your HSA employee contribution election form.

1. Click ‘Get Form’ button to obtain the form and open it in your preferred editor.
2. In the Employer Name field, enter the name of your employer as required.
3. Complete the Account Owner’s Name and Address section by entering your last name, first name, and middle initial in the designated fields.
4. Fill in your street address, city, state, and zip code in the corresponding fields to provide your complete address.
5. Enter your Social Security Number along with your daytime and evening phone numbers to ensure accurate contact information.
6. Specify the amount you wish to contribute to your HSA account each pay period on a pre-tax basis by entering the amount in the designated field.
7. Indicate the amount you wish to contribute on a post-tax basis by filling out the corresponding field.
8. If applicable, enter a single contribution amount and specify whether it is pre-tax or post-tax. Note that this will only be deducted once for the specified tax year.
9. Review the eligibility responsibility statement and acknowledge that it is your duty to determine if you are eligible to make contributions and to ensure that contributions do not exceed the annual limits.
10. Sign the form as the account owner and include the date to validate your submission.
11. Once all sections are completed, save your changes, then download, print, or share the form as needed.

Complete your HSA employee contribution election form online today!