For Employee S Contribution to H.S.A. Bank Account

WESTON BOARD OF EDUCATION

H.S.A. PAYROLL DEDUCTION AUTHORIZATION

FOR EMPLOYEE’S CONTRIBUTION TO H.S.A. BANK ACCOUNT

2016-2017 SCHOOL YEAR

Employee Name: ______

(PLEASE PRINT CLEARLY)

I agree to reduce my eligible compensation by $______

Each pay period (beginning the first pay of September 2016 and ending the last pay of June2017– 20 pays total)as a pre-tax contribution to my H.S.A. bank account

______

Employee Signature / Please Sign Clearly Date

TEACHERS - Participant is not required to make an HSA contribution. Participants may choose to fund any amount up to the maximum allowed by the IRS guidelines. If participant chooses to contribute to the HSA, total contributions including the employer’s, for 2016 cannot exceed $3,350 for Single and $6,750 for Family (Participants can contribute an additional $2,350 for Single and $4,750Family). Participant must be enrolled in the HSA plan to make a qualified contribution. Participants 55 years or older may be eligible for an additional $1,000 "catch up" contribution per year.

NON-CERTIFIED STAFF 10 and 11 MONTHS ONLY- Participant is not required to make an HSA contribution. Participants may choose to fund any amount up to the maximum allowed by the IRS guidelines. If participant chooses to contribute to the HSA; total contributions, including the employer's for 2016, cannot exceed federal limit of $3,350 for Single and $6,750 for Family (employee wishing to contribute to the full federal maximum may contribute $2,150 for Single and $4,350 for Family). Participant must be enrolled in the HSA plan to make a qualified contribution. Members 55 years and older may be eligible for catch up contributions.

NON-CERTIFIED STAFF 12 MONTHS ONLY- Participant is not required to make an HSA contribution. Participants may choose to fund any amount up to the maximum allowed by the IRS guidelines. If participant chooses to contribute to the HSA; total contributions, including the employer's for 2016, cannot exceed federal limit of $3,350 for Single and $6,750 for Family (employee wishing to contribute to the full federal maximum may contribute $2,250 for Single and $4,550 for Family). Participant must be enrolled in the HSA plan to make a qualified contribution. Members 55 years and older may be eligible for catch up contributions.

ADMINISTRATORS - Participant is not required to make an HSA contribution. Participants may choose to fund any amount up to the maximum allowed by the IRS guidelines. If participant chooses to contribute to the HSA; total contributions, including the employer's for 2015, cannot exceed federal limit of $3,350 for Single and $6,750 for Family (employee wishing to contribute to the full federal.

maximum may contribute $2,350 for Single and $4,650 for Family). Participant must be enrolled in the HSA plan to make a qualified contribution. Members 55 years and older may be eligible for catch up contributions.