Bone & Joint Clinic
Employee Contribution Form
Health Savings Account Amounts
I _______________________________ elect to contribute $________________ per pay period into my Health Savings Account (HSA) with BMO Harris Bank. By signing below, I agree that I understand the following:
· Because HSA eligibility is determined on a monthly basis, I may elect to change the amount of my HSA deferral at any time. This change must be submitted in writing to Human Resources at least 7 days prior to the end of a month in order for the new election to take effect with the first pay period of the following month.
· I understand that amounts contributed to my HSA through payroll deduction will be exempt from federal taxes, but will be subject to applicable Wisconsin taxes.
· Once funds have been deposited into my HSA it is my responsibility to become familiar with and to comply with the laws and regulations pertaining to my HSA account.
· I understand that is my responsibility to ensure that I do not exceed the IRS allowed annual maximum that can be contributed to an HSA account. I also understand that all amounts put into my HSA as employer contributions by Bone & Joint Clinic will be counted toward this annual maximum.
________________________________________ ____________________________
Employee Signature Date Signed
HSA Account Number: ____________________________
Start my HSA deductions on the payroll dated ______________________ .
HR Use Only: Date submitted to payroll _____________________, By ___________