[{"data":1,"prerenderedAt":-1},["ShallowReactive",2],{"detail-sidebar-cat-1-en-105":3,"doc-seo-303853-105":53,"doc-detail-303853-en":126},{"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":119,"head_meta":121,"extra_data":123,"updated_unix":125},105,"en","health-savings-account-contribution-form-payroll-deduction-form-2026","Health Savings Account Contribution Form -Payroll Deduction - Form 2026","","Health Savings Account (HSA) contribution form for payroll deduction, collecting employee name, contribution amount, and designation for tax year 2026. It explains timing and availability of deposits, including that prior-year deposits must meet the tax filing deadline and IRS rules do not allow extension-based contributions. The form provides regular and catch-up contribution guidance, outlines authorization and applicable contribution rules, and includes instructions for resolving mistaken distributions per IRS Notice 2004-50, with benefits contact details for questions.",{"@graph":63,"@context":118},[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/health-savings-account-contribution-form-payroll-deduction-form-2026/303853/",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/health-savings-account-contribution-form-payroll-deduction-form-2026/303853.png","ImageObject",442,249,{"name":88,"@type":89},"Mary Man","Person",{"url":68,"name":91,"@type":92},"DocShare","Organization","application/pdf","2026-09-28","2026-09-19",true,{"@type":98,"interactionType":99,"userInteractionCount":73},"InteractionCounter",{"@type":100},"ViewAction",{"@type":102,"mainEntity":103},"FAQPage",[104,110,114],{"name":105,"@type":106,"acceptedAnswer":107},"When will payroll-deducted HSA contributions take effect?","Question",{"text":108,"@type":109},"The deduction amount takes effect the next payroll date following the signed and dated agreement.","Answer",{"name":111,"@type":106,"acceptedAnswer":112},"Are HSA contributions allowed to be submitted using a tax filing extension?",{"text":113,"@type":109},"No. The IRS does NOT allow an extension of time to contribute to an HSA, even if an extension is granted for filing taxes.",{"name":115,"@type":106,"acceptedAnswer":116},"What are catch-up contributions and who may make them?",{"text":117,"@type":109},"If you are 55 years of age or older during the calendar year, you may make an additional catch-up contribution of up to $1,000.","https://schema.org",{"og:url":78,"og:type":120,"og:title":59,"og:site_name":91,"og:description":61},"article",{"robots":122,"canonical":78},"index,follow",{"doc_id":124,"site_id":56},303853,1790579588,{"code":4,"msg":5,"data":127},{"doc_id":124,"user_id":128,"nickname":88,"user_avatar":129,"doc_module":9,"category_id":35,"category_name":36,"doc_title":59,"doc_description":61,"doc_content":130,"file_id":131,"file_url":132,"file_type":133,"file_size":134,"view_count":73,"is_deleted":4,"is_public":9,"is_downloadable":9,"audit_status":9,"page_count":9,"language":135,"language_code":57,"site_id":56,"html_lang":57,"table_of_contents":136,"faqs":137,"seo_title":138,"seo_description":61,"update_tm":139,"read_time":4},7421720224475,"https://ap-avatar.wpscdn.com/davatar_276721f389ce27ea32af1340a28f341c","Health Savings Account Contribution Form -Payroll Deduction  \nForm  \nStep 1:  Information  \nEmployee Name-Please Print  \nStep 2: Contribution Information  \nNote: Deposits may not be available for immediate withdrawal  \nContribution Amount  \nContribution  \nfor Tax Year  \n2026  \nNote: Prior year deposits must be received by the tax filing deadline of the following year, typically April 15. The IRS does NOT allow an extension of time to contribute to an HSA, even if you have an extension for filing your taxes. If a year is not specified, your contribution will be deposited for the year in which it was received.  \n\n|  |\n| --- |\n|  |\n|  |\n\nRegular ~~ ~~  $4,400  $8,750 Catch-up ~~ ~~  \nStep 3: Consumer Authorization  \nI certify that I am the HSA member or an individual authorized to execute this transaction. I have read and understand the instructions and any rules or conditions  \n*Accountholder Signature Date  \nRules and Conditions Applicable to Contributions  \n\n| General Information | The deduction amount will take effect the next payroll date following this signed and dated agreement. |\n| --- | --- |\n| Contribution Type | Regular\u003Cbr>Annual maximum contribution limits can vary from year to year. For current contribution maximums, visit our Frequently Asked Questions section at [http://www.hsabank.com/hsabank/accountholders/frequently-asked-questions](http://www.hsabank.com/hsabank/accountholders/frequently-asked-questions).\u003Cbr>Catch-Up\u003Cbr>If you are 55 years of age or older during the calendar year, you may make an additional ~~ ~~ catch up ~~ ~~ contribution of up to $1,000 . Mistaken Distribution\u003Cbr>According to IRS Notice 2004-50, an HSA Custodian or Trustee may allow the return of mistaken distributions. The Custodian or Trustee may rely on the Accountholders representation that the distribution was, in fact, a mistake. |\n\nPlease contact Benefits at [benefits@psta. net](benefits@psta. net) or call the benefits hotline @ 727-540-1987 if you have any questions.  \n© 2014 HSA Bank. HSA Bank is a division of Webster Bank, N.A., Member FDIC. FORM_Health_Savings_Account_Contribution_071414","cbCaiuMt3nZF8Bl7","https://ap.wps.com/l/cbCaiuMt3nZF8Bl7","pdf",1071303,"English","# Step 1: Information\n## Employee Name\n# Step 2: Contribution Information\n## Contribution Amount\n## Catch-up and contribution timing notes\n# Step 3: Consumer Authorization\n## Signature and certification\n# Rules and Conditions Applicable to Contributions\n## General information\n## Contribution type (Regular/Catch-Up)\n## Mistaken distribution","[{\"question\":\"When will payroll-deducted HSA contributions take effect?\",\"answer\":\"The deduction amount takes effect the next payroll date following the signed and dated agreement.\"},{\"question\":\"Are HSA contributions allowed to be submitted using a tax filing extension?\",\"answer\":\"No. The IRS does NOT allow an extension of time to contribute to an HSA, even if an extension is granted for filing taxes.\"},{\"question\":\"What are catch-up contributions and who may make them?\",\"answer\":\"If you are 55 years of age or older during the calendar year, you may make an additional catch-up contribution of up to $1,000.\"}]","Health Savings Account Contribution Form -Payroll Deduction - Form 2026 | PDF",1789807707]