Health Savings Account (HSA) EMPLOYEE CONTRIBUTION FORM 2026

1. Click ‘Get Form’ to open the Health Savings Account (HSA) EMPLOYEE CONTRIBUTION FORM in the editor.
2. Begin by entering your name in the 'Employee’s Name' field. Ensure that you print or type clearly for accuracy.
3. Fill in your Employee Number and Department & Division to help identify your account within the organization.
4. Provide your Work Number or Daytime Phone for any necessary follow-up regarding your contribution.
5. Indicate your desired Twice-Monthly Contribution Amount in the specified field, ensuring it aligns with IRS limits.
6. Review the note regarding contribution changes, ensuring you submit this form at least two weeks before the first pay date of the month.
7. Sign and date the form at the bottom to authorize Marion County to withhold contributions from your wages.
8. Before submitting, make a copy of the completed form for your records as advised.

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