Employee HSA Contribution Form 20110526 - HealthEquity 2026

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55 votes

The document is an Employee HSA Contribution Form that employees must complete to indicate their desired monthly contributions to a Health Savings Account (HSA). It includes personal information fields, contribution limits for the years 2011 and 2012 based on coverage type (single or family), and notes on eligibility and tax implications. The form is intended for internal use by the employer.

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Click ‘Get Form’ to open the Employee HSA Contribution Form 20110526 in the editor.
Begin by entering your name in the designated fields: First, Middle, and Last. Ensure accuracy for proper identification.
Input your Social Security Number in the provided space. This is crucial for processing your contributions.
Decide how much you would like to contribute to your HSA each month. Refer to the annual contribution limits based on your coverage type (Single or Family) for guidance.
Sign and date the form at the bottom. This confirms your intent and agreement to the contributions specified.

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Versions	Form popularity	Fillable & printable
2013	4.6 Satisfied (32 Votes)
2011	4.9 Satisfied (55 Votes)

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Got questions?

We have answers to the most popular questions from our customers. If you can't find an answer to your question, please contact us.

How do I get a copy of my HSA tax form?

There are two sets of tax forms: Your annual tax Form 1099 will be mailed to the address on file by January 31 each year. Your annual tax Form 5498 will be mailed to the address on file by May 31 each year.

What if I didnt get a 1099-SA for my HSA?

Even if you do not receive Form 1099-SA, you are still responsible for reporting the income from your HSA or MSA distributions on your tax return. You can use the information you have available, such as your account statements, to determine the amount of distributions you received during the year.

What if I didnt get a 8889 form?

If you didnt receive yours, contact your HSA administrator or your employers HR department.

What form shows employee HSA contributions?

File Form 8889 to: Report health savings account (HSA) contributions (including those made on your behalf and employer contributions). Figure your HSA deduction. Report distributions from HSAs.

How do I get my 1099-SA form for health equity?

Visit the Account Statements page in your online account to access your HSA tax documents. File Form 1099-SA to report distributions from an HSA.

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