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Health Savings Account (HSA) EMPLOYEE CONTRIBUTION FORM 2026
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- Click ‘Get Form’ to open the Health Savings Account (HSA) EMPLOYEE CONTRIBUTION FORM in the editor.
- Begin by entering your name in the 'Employee’s Name' field. Ensure that you print or type clearly for accuracy.
- Fill in your Employee Number and Department & Division to help identify your account within the organization.
- Provide your Work Number or Daytime Phone for any necessary follow-up regarding your contribution.
- Indicate your desired Twice-Monthly Contribution Amount in the specified field, ensuring it aligns with IRS limits.
- Review the note regarding contribution changes, ensuring you submit this form at least two weeks before the first pay date of the month.
- Sign and date the form at the bottom to authorize Marion County to withhold contributions from your wages.
- Before submitting, make a copy of the completed form for your records as advised.
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Complete section A. Indicate the pretax amount you would like to contribute annually to your health savings account. Submit the completed and signed form to:
Use this form to indicate the amount of your payroll contributions to be placed in your Health Savings Account (HSA). maximums of $4,400 for individual