In order to make contributions to the HSA, the employee must be enrolled in the Personal Choice High Deductible Health Plan (HDHP) for the entire duration in which HSA contributions are made. The employee (and family members, if also enrolled in the...Health Savings Account Contribution Agreement • August 24th, 2012
This Agreement shall be legally binding and irrevocable as to each of the parties hereto while the employment continues; provided, however, either party may change or terminate this Agreement as of the end of any month (or pay period, if applicable), so that it will not apply to salary subsequently earned, by giving written notice of the date of change or termination; and provided further, in the case of an employee who is paid bi-weekly, that no more than one agreement is completed in any given calendar month.
Blue Springs School District Employee Health Savings Account Contribution AgreementHealth Savings Account Contribution Agreement • July 19th, 2010
Plan Year 1/01/2021 through 12/31/2021Health Savings Account Contribution Agreement • November 19th, 2020
Effective with respect to amounts earned on or after / / , which date is subsequent to the execution of this Agreement, the employee’s basic salary will be reduced by the amount indicated below and forwarded to the employee’s HSA account at PNC Bank. If the employee does not wish to have a PNC account and has a current HSA with a bank of their choice, Please note the routing number and account number of that bank for the Knox College contribution only. (Salary reductions require an account through PNC.)
BY THIS AGREEMENT, MADE BETWEENHealth Savings Account Contribution Agreement • November 17th, 2017
Effective with respect to amounts earned on or after / / , which date is subsequent to the execution of this Agreement, the employee’s basic salary will be reduced by the amount indicated below and forwarded to the employee’s HSA account at PNC Bank. If the employee does not wish to have a PNC account and has a current HSA with a bank of their choice, Please note the routing number and account number of that bank for the Knox College contribution only.
Effective with respect to amounts earned on or after / / , which date is subsequent to the execution of this Agreement, the employee’s basic salary will be reduced by the amount indicated below and the College will deposit a corresponding amount into...Health Savings Account Contribution Agreement • September 8th, 2020
This Agreement shall be legally binding and irrevocable as to each of the parties hereto while the employment continues; provided, however, either party may change or terminate this Agreement as of the end of any month (or pay period, if applicable), so that it will not apply to salary subsequently earned, by giving written notice of the date of change or termination; and provided further, in the case of an employee who is paid bi-weekly, that no more than one agreement is completed in any given calendar month.
ContractHealth Savings Account Contribution Agreement • November 21st, 2016
Purpose: Use this form to make changes to your contributions to your HSA. This may be a one-time contribution or a change to your bi-weekly contribution amounts.
HEALTH SAVINGS ACCOUNT IMPORTANT INFORMATION – PLEASE READ CAREFULLYHealth Savings Account Contribution Agreement • October 6th, 2022
If you wish to make pre-tax contributions to your Health Savings Account (HSA), you will need to complete and sign this HSA Salary Reduction Agreement and return it to Finance no later than the last day of the month preceding the month in which you wish to begin your contributions.
