OTTERBEIN UNIVERSITY HEALTH SAVINGS ACCOUNT PAYROLL DEDUCTION CHANGE FORM

(FORM MUST BE RETURNED TO HUMAN RESOURCES)

Please use this form to authorize a change in the automatic deductions from your paycheck contributed to your Health Savings Account (HSA). After completing, please make a copy for your records and give the original form to Human Resources. If you have any questions when completing this form, please contact Human Resources.

First Name / Middle Initial / Last Name

Otterbein ID Number

Reminder: The maximum employee contribution amount, combined with Otterbein’s employer contribution, cannot exceed the IRS stated maximums for the calendar year. In 2013, the limits are $3,250 for individuals and $6,450 for family coverage. Individuals age 55 and older can make additional catch-up contributions. Check the IRS guidelines for maximum contributions at www.treas.gov and click on Health Savings Accounts.

I would like to change my contribution to the following amount for direct deposit into my Health Savings Account, through pre-tax payroll deductions:

$ / per pay period
Effective for Payroll Dated:

·  I authorize my employer to reduce my pay before taxes on a “per pay period” basis as indicated above.

·  I understand my contribution election (if any) is for calendar year 2013 and that I can add, change or revoke my HSA contribution prior to any future pay date in accordance with payroll processing dates.

·  I understand that my changes must be prospective in accordance with Internal Revenue Code (IRC) rules.

·  I understand that my election contributions must comply with federal regulations and Otterbein’s internal plan guidelines.

·  I understand that to avoid taxes and penalties, the reimbursement requests I will be submitting to my HSA account must be IRC eligible medical expenses and that I must not have been previously reimbursed for these expenses from insurance or any other source.

·  I understand that I will need to make new elections for the following year.

·  I understand that in connection with my signed authorization on the Health Savings Account Enrollment Information form, Otterbein University may also reduce my pay on an after-tax basis for any ineligible contributions Otterbein University makes to my Health Savings Account in accordance with that authorization.

Signature: Date: