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Get UT HealthEquity Employee HSA Contribution Form 2013-2024

Social Security Number: XXXXXXXXXXXXX How much would you like to contribute to your HSA each month? $ (Not sure how much you can contribute to your HSA? Use the information below.) Signature Date 2013 Annual HSA Contributions Coverage Type Maximum Allowed Single $3,250 Family $6,450 *Catch-up contribution (age 55 +) is $1,000 Your eligibility to contribute to an HSA is determined by the effective date of your HDHP coverage.

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