HSA Application and Salary Reduction Agreement

This Salary Reduction Agreement (SRA) authorizes your employer to reduce your salary by the indicated amount shown below for the exclusive purpose of facilitating a contribution to your Health Savings Account.

Do not send contributions with this form.

By completing this agreement, you are indicating that as of the effective date of your contribution election, you are an “Eligible Individual” as defined in the adoption agreement and authorize your employer to facilitate your monthly contributions to your HSA on your behalf.