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Wauwatosa School District Contribution Form Health Savings Account (HSA)

New Enrollment

Contribution Amount Change

First Name:*

Last Name:*

Date of Birth

Social Security Number:

Address Line 1:*

Address Line 2:

City:*

State:*

Zipcode:*

I hereby make the following HSA elections, to be effective on the next permissible payroll check (FSA elections should be made on a separate FSA Enrollment Form):

Health Savings Account (HSA) Contribution Amount

Maximum Allowable Annual Contribution 2021: $3,600/single plan, $7,200/family plan.
Please note that employees who are ages 55 and older may make an additional “catch up” contribution of $1,000/year

My Per Pay Period Election:*

I have received and have read the materials given to me explaining the Health Savings Account Plan. I understand that my decision regarding this election is effective for all future payrolls, for this year and for future years, unless I notify Human Resources, in advance, of a change to my election, which may be made periodically as authorized by the district.

I authorize the District to reduce my salary by the amounts indicated above to pay for the benefits I have elected, and I understand that I will be responsible for monitoring my HSA at all time in the future. Although I intend to make the elected contributions on a pre-tax basis, I acknowledge that the District is not responsible for the tax treatment of my contributions. I also acknowledge that the District may decide that it needs to limit or reduce my contributions in the future.

Participant’s Signature:

Sign Document

Clear

Done

Printed Signature:*

Date:*

*Form Updated 1/1/2021