[{"data":1,"prerenderedAt":-1},["ShallowReactive",2],{"detail-sidebar-cat-1-en-105":3,"doc-seo-303852-105":53,"doc-detail-303852-en":118},{"code":4,"msg":5,"data":6},0,"success",[7,14,19,24,29,34,39,44,49],{"id":8,"doc_module":9,"doc_module_name":10,"category_name":11,"show_sort_weight":12,"slug":13},11,1,"Template","Presentations",90,"presentations",{"id":15,"doc_module":9,"doc_module_name":10,"category_name":16,"show_sort_weight":17,"slug":18},12,"Resumes",80,"resumes",{"id":20,"doc_module":9,"doc_module_name":10,"category_name":21,"show_sort_weight":22,"slug":23},14,"Invoices",70,"invoices",{"id":25,"doc_module":9,"doc_module_name":10,"category_name":26,"show_sort_weight":27,"slug":28},15,"Posters",60,"posters",{"id":30,"doc_module":9,"doc_module_name":10,"category_name":31,"show_sort_weight":32,"slug":33},16,"Social Media",50,"social-media",{"id":35,"doc_module":9,"doc_module_name":10,"category_name":36,"show_sort_weight":37,"slug":38},17,"Forms",40,"forms",{"id":40,"doc_module":9,"doc_module_name":10,"category_name":41,"show_sort_weight":42,"slug":43},18,"Letters",30,"letters",{"id":45,"doc_module":9,"doc_module_name":10,"category_name":46,"show_sort_weight":47,"slug":48},21,"Paper Templates",5,"papers-templates",{"id":50,"doc_module":9,"doc_module_name":10,"category_name":51,"show_sort_weight":4,"slug":52},158,"General","general-158",{"code":4,"msg":54,"data":55},"ok",{"site_id":56,"language":57,"slug":58,"title":59,"keywords":60,"description":61,"schema_data":62,"social_meta":111,"head_meta":113,"extra_data":115,"updated_unix":117},105,"en","2026-health-savings-account-hsa-contribution-form","2026 Health Savings Account (HSA) Contribution Form","","Employees enrolling in the HSA Medical Plan must complete this Health Savings Account (HSA) Contribution Form and submit it to Human Resources Benefits. The form confirms enrollment plans, eligibility to open or contribute, and understanding of how contributions are initiated through the employer or authorized agents. It outlines annual city contributions in four equal deposits, employee contribution options (cancel, annual change, short term change), IRS annual contribution limits, payroll deduction options, and any applicable wellness-related one-time deposits. It also includes HR fields and employee signature and identification details.",{"@graph":63,"@context":110},[64,80,101],{"@type":65,"itemListElement":66},"BreadcrumbList",[67,71,74,77],{"item":68,"name":69,"@type":70,"position":9},"https://docshare.wps.com","Home","ListItem",{"item":72,"name":10,"@type":70,"position":73},"https://docshare.wps.com/template/",2,{"item":75,"name":36,"@type":70,"position":76},"https://docshare.wps.com/template/forms/",3,{"item":78,"name":59,"@type":70,"position":79},"https://docshare.wps.com/template/2026-health-savings-account-hsa-contribution-form/303852/",4,{"url":78,"name":59,"@type":81,"image":82,"author":87,"headline":59,"publisher":90,"fileFormat":93,"inLanguage":57,"description":61,"dateModified":94,"datePublished":95,"encodingFormat":93,"isAccessibleForFree":96,"interactionStatistic":97},"DigitalDocument",{"url":83,"@type":84,"width":85,"height":86},"https://docshare.wps.com/thumbnails/2026-health-savings-account-hsa-contribution-form/303852.png","ImageObject",442,249,{"name":88,"@type":89},"Aldword","Person",{"url":68,"name":91,"@type":92},"DocShare","Organization","application/pdf","2026-10-01","2026-09-19",true,{"@type":98,"interactionType":99,"userInteractionCount":47},"InteractionCounter",{"@type":100},"ViewAction",{"@type":102,"mainEntity":103},"FAQPage",[104],{"name":105,"@type":106,"acceptedAnswer":107},"What limits affect how much total can be contributed to the HSA?","Question",{"text":108,"@type":109},"The form lists 2026 IRS annual contribution limits and notes that the employee’s total annual contribution plus any other sources, including the City’s contribution, may not exceed the IRS annual maximum. It also includes guidance for age 55+ catch-up contributions when applicable.","Answer","https://schema.org",{"og:url":78,"og:type":112,"og:title":59,"og:site_name":91,"og:description":61},"article",{"robots":114,"canonical":78},"index,follow",{"doc_id":116,"site_id":56},303852,1790522928,{"code":4,"msg":5,"data":119},{"doc_id":116,"user_id":120,"nickname":88,"user_avatar":121,"doc_module":9,"category_id":35,"category_name":36,"doc_title":59,"doc_description":61,"doc_content":122,"file_id":123,"file_url":124,"file_type":125,"file_size":126,"view_count":79,"is_deleted":4,"is_public":9,"is_downloadable":9,"audit_status":9,"page_count":9,"language":127,"language_code":57,"site_id":56,"html_lang":57,"table_of_contents":128,"faqs":129,"seo_title":130,"seo_description":61,"update_tm":131,"read_time":4},2336478940917,"https://ap-avatar.wpscdn.com/davatar_6f874abed73319feea01a86fa6f0fab8","Employees enrolling in the HSA Medical Plan MUST fill out this form and return it to the Human Resources Benefits Office.  \n\n| 2026 Health Savings Account (HSA) Contribution Form\u003Cbr>By my signature below, I certify that I have enrolled, or plan to enroll, in an HSA-compatible health plan and that I am not covered under any other plan that would disqualify me from opening or contributing to my HSA. I understand that this form is provided for convenience purposes and that HSA Bank will not initiate contributions to my HSA, but will allow my employer or their authorized agent to initiate contributions to my account. |  |  |  |  |  |  |  |\n| --- | --- | --- | --- | --- | --- | --- | --- |\n| ONLY THOSE EMPLOYEES ON THE HSA MEDICAL PLAN WILL RECEIVE ANNUAL CITY\u003Cbr>CONTRIBUTIONS IN FOUR EQUAL DEPOSITS |  |  |  |  |  |  |  |\n| 􀀁 January 1- $250 (Family), $150 (Individual)\u003Cbr>􀀁 July 1- $250 (Family), $150 (Individual) |  |  |  |  | 􀀁 April 1- $250 (Family), $150 (Individual)\u003Cbr>􀀁 October 1- $250 (Family), $150 (Individual) |  |  |\n| |  |  | OPTION 1–Cancel Contributions\u003Cbr>I do not want to contribute to my HSA through a pre – tax salary reduction. I understand that at any time I can make after-tax contributions to my HSA online- through Internet Banking ([https://Secure.hsabank.com/ibanking](https://Secure.hsabank.com/ibanking)), or by mailing a check with contribution Form.\u003Cbr>OPTION 2–Annual Change\u003Cbr>I elect to contribute to my HSA with a pre-tax salary reduction through my employer’s Section 125 Cafeteria Plan, and authorize my employer to deduct the amounts as indicated from my salary and forward the funds to HSA Bank to deposit in my HSA.\u003Cbr>OPTION 3–Short Term Change\u003Cbr>Payroll Start Date:  \u003Cbr>Payroll End Date:   |  | 2026 IRS Annual Contribution Limits\u003Cbr>HSA Individual Coverage  $4,400\u003Cbr>**$3,800 after City’s $600 contribution without Wellness ($146.15 bi-weekly max)\u003Cbr>**$3,400 after City’s $600 contribution & $400 Wellness ($130.76 bi-weekly max)\u003Cbr>HSA Family Coverage  $8,750\u003Cbr>**$7,750 after City’s $1,000 contribution without Wellness ($298.07 bi-weekly max)\u003Cbr>**$6,750 after City’s $1,000 contribution & $1,000 Wellness ($259.61 bi-weekly max)\u003Cbr>HDHP Individual Coverage $4,400\u003Cbr>($169.23 bi-weekly max) |  |  |\n|  |  | Payroll Deduction Options per bi-weekly period\u003Cbr>(check one)\u003Cbr>  Maximum Single Contribution**   Maximum Family Contribution**   Any other bi-weekly amount $   |  | HDHP Family Coverage $8,750\u003Cbr>($336.53 bi-weekly max)\u003Cbr>Age 55+ Catch-up amount $1,000\u003Cbr>**Note: Your Total Annual Employee Contribution along with contributions from any other sources ( including the City’s contribution for the year) may not exceed the Annual Maximum Contribution amount set by the IRS. |  |  |  |\n| **Including the 55+ catch-up contribution amount, if applicable. |  |  |  |  |  |  |  |\n|  | IF YOU COMPLETED MOVING TOWARDS WELLNESS IN THE CURRENT YEAR, YOU WILL SEE A ONE-TIME DEPOSIT OF $400 (INDIVIDUAL) OR $1,000 (FAMILY) INTO YOUR HSA ACCOUNT ON OR ABOUT JANUARY 1 OF THE FOLLOWING YEAR. |  |  |  |  |  |  |\n| To be completed by the Human Resources Department:\u003Cbr>YTD Contributions $  \u003Cbr>Total Annual Employee Contribution $ \u003Cbr>(Bi-weekly deduction x   paychecks)\u003Cbr>Total Annual City Contribution $ \u003Cbr>Total Annual Contribution $ \u003Cbr>(May not exceed the contribution limits above) |  |  |  |  |  | Employee Name: (Please Print)\u003Cbr>Employee Signature:\u003Cbr>Date:  \u003Cbr>Employee ID \\#:   |  |","cbCaiaAV2PBbwJsT","https://ap.wps.com/l/cbCaiaAV2PBbwJsT","pdf",111899,"English","# Contribution Form Overview\n## Enrollment Eligibility Certification\n## Annual City Contributions Schedule\n## Employee Contribution Options\n## 2026 IRS Annual Contribution Limits\n## Payroll Deduction and Change Options\n## HR Completion Fields and Employee Signature","[{\"question\":\"What limits affect how much total can be contributed to the HSA?\",\"answer\":\"The form lists 2026 IRS annual contribution limits and notes that the employee’s total annual contribution plus any other sources, including the City’s contribution, may not exceed the IRS annual maximum. It also includes guidance for age 55+ catch-up contributions when applicable.\"}]","2026 Health Savings Account (HSA) Contribution Form | PDF",1789807707]