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Get (HSA) Contribution Election Change Form - Human Resources ...

Requested Effective Date for the Deduction Change: (Enter the first day of the requested month.) Requested Annual Election Pledge: $ (Total amount you want to elect for this calendar year. To stop deductions, enter $0) Requested Bi-Weekly HSA Pre-tax Deduction Amount: $ (Divide the annual amount you wish to contribute by number of remaining pay periods, to calculate your bi-weekly deductions.) Is this a One-time Deduction: Yes No ACS Mell.

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