Health Equity ENROLLMENT FORM

Health Equity Enrollment Form
Full Name*

First NameLast Name
MI
Social Security Number
Street Address*
City*
State*
Zip*
Phone Number*
Email Address*
example@example.com
Date of Birth*

MonthDayYear
Please make a selection.*

I do not wish to contribute.I wish to contribute to my HSA account each pay period on a pre-tax basis. I understand this amount will be deducted from my paycheck until I indicate otherwise.I wish to make a single contribution to my HSA account on a pre-tax basis. I understand this will be deducted from my paycheck one time only for the tax year.
Contribution Amount Per Paycheck
Single Contribution Amount
Important

The annual maximum is the applicable statutory maximum for my High Deductible Health Plan (HDHP) coverage type (i.e., single or family The IRS may adjust this amount each year. Contributions are prorated based on the number of months I am covered under an HDHP. An exception to this rule allows participants with an HSA who are covered on December 1 to contribute the entire amount for the year. My HSA contribution election can be changed prospectively, for any reason.

By electing HSA benefits, I am certifying that I meet the requirements under Internal Revenue Code § 223 to be eligible to contribute to an HSA. I understand that:
- I must be covered by an HDHP to contribute to an HSA.
- I may not be claimed as a dependent on another individual's income tax return.
- I may not be covered by other medical coverage, including Medicare or my spouse's traditional medical Flexible Spending Account.
- HSA benefits cannot be elected in addition to medical spending account reimbursements unless the Limited Purpose option is selected.
For more information about HSA eligibility requirements, see IRS Publication 969.
It is my responsibility to determine (1) whether I am eligible to make contributions to my HSA, and (2) whether contributions to this HSA have exceeded the applicable maximum annual contribution limit.
Signature*

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Date Signed*

MonthDayYear
Date
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Health Equity Enrollment Form