Get Employee Authorization For Payroll Deduction To Health Savings Account Use This Form To Withhold

This guide provides clear and supportive instructions for completing the Employee Authorization For Payroll Deduction To Health Savings Account form online. Understanding each section and accurately filling out the required fields is essential for effective payroll deductions to your health savings account.

Follow the steps to fill out the form accurately.

1. Click ‘Get Form’ button to obtain the form and open it in the editor.
2. Complete Section 1 by entering your personal information, including your name, mailing address, MTSU Banner ID, and work phone number. Be sure to double-check the accuracy of this information.
3. In Section 2, calculate your maximum HSA contribution. Select your enrollment status as either individual or family HSA. Refer to the maximum contribution amounts for the year 2016—$3,350 for individual and $6,750 for family. If you are age 55 or older, factor in an additional $1,000.
4. Calculate how much your employer will contribute in 2016 if applicable, and finalize the maximum contribution by subtracting the employer's contribution from the total calculated in Section 2.
5. Continue to Section 3 to determine your per-paycheck contribution. Use the total from Section 2 and divide it by the number of paychecks you will receive in 2016 to find the maximum you can contribute per paycheck.
6. Enter the amount you wish to contribute per paycheck, ensuring it does not exceed the maximum you calculated in the previous step.
7. Sign and date the form in the designated area to confirm your request for payroll deductions as outlined. Make sure to review all information for accuracy before submitting.
8. After completing the form, save your changes and download or print a copy for your records. Submit the completed form to MTSU Human Resources by the deadline to ensure your deductions are processed.

Complete your documents online today to manage your health savings account effectively.