Fax form to OHR – Benefits Design & Management at 480-993-0007 Page 1 HR Benefits Design & Management January 2012

HSA PAYROLL DEDUCTION AUTHORIZATION

2012

Fax form to OHR Benefits Design & Management 480-993-0007

FORM COMPLETION INSTRUCTIONS 1. Complete section A. 2. Complete section B.

Please indicate whether this is a new contribution (new hire/newly eligible) of if you are making a contribution change.

Indicate the pre-tax amount you would like to contribute for the above calendar year; this is in addition to the University contribution to your Health Savings Account.

If you are changing your contribution, please indicate the total contribution you want to make for the above calendar year.

3. Sign and date and retain a copy.

4. Submit the completed and signed form to HR Benefits fax #480-993-0007. SECTION A: EMPLOYEE IDENTIFICATION NAME (LAST, FIRST, MI)

PHONE NUMBER DATE OF BIRTH

STREET ADDRESS

EMPLOYEE ID(10 DIGIT) DATE OF HIRE

CITY, STATE, ZIP

EMAIL ADDRESS

SECTION B: EMPLOYEE VOLUNTARY CONTRIBUTION AMOUNT to HEALTH SAVINGS ACCOUNT (subject to contribution limits – see page 2)

New contribution

Change contribution (indicate below the dollar

amount that you want to contribute in total by the end of the above calendar year)

COVERAGE LEVEL Employee Only

Employee + Adult

Employee + Child

Family

I elect an employee calendar year contribution of $__________________ (please refer to Employee Maximum Contributions – see page 2). Payroll deductions are taken on a pre-tax basis. Any change to an existing Payroll Deduction will be effective no sooner than the first day of the pay period following receipt of a signed authorization form. This authorization will remain in effect until a new authorization is received or until I cancel my Aetna HSA medical plan.

I affirm that I am enrolled in the State of Arizona’s HSA Option, have no other medical coverage, and am not participating in a Health Care Flexible Spending Account. I am eligible to open and contribute to a health savings account. I hereby request and authorize Arizona State University to deduct from my pay the above-identified deduction and to forward it to my health savings account with JPMorgan Chase. I understand it is my responsibility to manage my contributions in accordance with federal guidelines based on my eligibility as well as my dependents. I also understand that using my HSA funds for expenses other than those deemed qualified may subject me to tax penalties.

Employee’s Signature: _________________________________________ Date: _________________________________

Fax form to OHR – Benefits Design & Management at 480-993-0007 Page 2 HR Benefits Design & Management January 2012

MAXIMUM HSA CONTRIBUTION Every year the Internal Revenue Service (IRS) sets maximum contribution limits for Health Savings Accounts (HSA’s). Failure to observe these limits may results in individual tax penalties. JPMorgan Chase is required to report HSA contribution information to the IRS.

Coverage level Under age 55 Age 55+ Employee only 720 720

Employee + adult 1,440 1,440

Employee + child 1,440 1.440

Family 1,440 1,440

Coverage level Under age 55 Age 55+

Employee only 2,380 3,380

Employee + adult 4,810 5,810

Employee + child 4,810 5,810

Family 4,810 5,810

Coverage level Under age 55 Age 55+

Employee only 3,100 4,100

Employee + adult 6,250 7,250

Employee + child 6,250 7,250

Family 6,250 7,250

EMPLOYEE MAXIMUM

CONTRIBUTION

COMBINED

CONTRIBUTION

(ASU + Employee)

ASU

CONTRIBUTION