Indiana Area School District
2016 HEALTH SAVINGS ACCOUNT PRE-TAX SALARY REDUCTION ELECTION
First Name / MI / Last NameSocial Security # / - / -
I understand that I may elect to make pre-tax contributions to my Highmark Bank of America Health Savings Account through payroll deduction. These pre-tax contributions are available under my employer’s Section 125 Plan. When making this election I will consider that any contributions being made by my employer will also be counted toward my HSA contribution limits which for 2016 are $3,350 for Individual and $6,750 for Family (with a catch up provision for anyone over the age 55 years for an additional $1,000 over the respective category limit).
Important: I understand that I cannot contribute to the Health Savings Account if I am also covered by another health plan or contribute to a Flexible Spending Account.
Please make your election below, then sign and date your form and submit to the District Administration Office.
o I elect to make pre-tax contributions to my Highmark Bank of America Health Savings Account Health Savings Account on the 1st & 2nd pays only. I understand that the contribution(s) I have selected will be made with pre-tax salary reductions and that such reductions reduce my compensation for Social Security benefit purposes.
$ / . / x / 2 / 4 / = / $ / .CONTRIBUTION PER PAY PERIOD / # OF PAY PERIODS / YOUR ANNUAL ELECTION AMOUNT
o I elect to decline the option to make pre-tax contributions Highmark Bank of America Health Savings Account through payroll deduction.
Employee Signature Date