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Health Savings Account (HSA) Contribution Change Form

This form should be used to make changes to your Health Savings Account (“HSA”) contribution. Changes can be made to your HSA contribution at any time. You can increase, decrease, or stop your semi-monthly contribution, provided you are enrolled in a high deductible health plan (“HDHP”) and you do not exceed the limits set by the IRS.

The maximum annual contributions set by the IRS in 2019 are: $ 3,500 for an individual: $7,000 for a family. Southwestern Michigan College currently contributes the following amounts: $1,000 per year for single subscribers, $1,500 per year for double subscribers, and $2,000 per year for family subscribers. Annual contribution limits apply regardless of whether the contributions are made by an individual, the individual’s employer, or any other person. If you're 55 or older in 2019, you can contribute an additional $1,000, or a total of $4,500 to an HSA for singles and $8,000 for families per year.

It is the employee’s responsibility not to exceed the IRS maximum contribution limit(s).

Personal Information
HSA Contribution Information
(If no date is provided, the next available payroll date will be used)
$ per pay period
$ per pay period
Enter your updated contribution per pay period based on 24 pay periods.
$
(After one-time contribution is made the HSA contribution will revert back to the Current Contribution Amount unless otherwise noted.)

To ensure timely effectiveness of this change, this form must be submitted by 8:00 a.m. the Monday morning of a pay week to be effective for that pay. Otherwise the next available payroll will be used.

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