All changes for the 12/21/17 payroll must be in by Wednesday December 13 at noon.

HSA Voluntary Pre-Tax Deduction Form

Employee Information

Last Four of Social Security Number

2017 Contribution Information

	2017 Maximum Allowable Contribution	SPS Contribution	Maximum Amount Employee Can Contribute in 2017
Less Than Age 55	Individual:$3,400	$1,000	$2,400
	Family:$6,750	$2,000	$4,750
Age 55 or Higher*	Individual:$4,400	$1,000	$3,400
	Family:$7,750	$2,000	$5,750

*Catch-up contributions can be made any time during the year in which the HSA participant turns 55

Election Type

Election Amount

Effective Date

This deduction will be taken only from the paycheck indicated in the effective date above.

This deduction will be stopped starting with the paycheck indicated in the effective date above.

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First Name

Last Name

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I agree to electronically sign and to create a legally binding contract between the other party and myself, or the entity I am authorized to represent.