Payroll Deduction form HSA 2012 - Benefitoptions az - benefitoptions az-2025

1. Click ‘Get Form’ to open it in the editor.
2. Begin by entering your personal information in the designated fields. Fill in your name, phone number, street address, city, state, zip code, employee ID number, and date of birth. Ensure all details are accurate for processing.
3. Select your agency and input your date of hire. This information is crucial for verifying your employment status.
4. Review the maximum HSA contribution limits provided for different tiers. Choose the appropriate tier that applies to you: Employee only, Employee+Adult, Employee+Child, or Family.
5. In the section labeled 'I elect a bi-weekly contribution of $____', enter the amount you wish to contribute each pay period. Make sure this amount does not exceed IRS limits.
6. Fill in the effective date and end date for your payroll deductions. This specifies when your contributions will start and stop.
7. Finally, sign and date the form at the bottom to authorize the deductions from your pay. Ensure you return it to the ADOA Benefit Services Division or your agency liaison as instructed.

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