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Pelican HSA 775 Health Savings Account Enrollment and Payroll Deduction/Change Form

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As a reminder, employees selecting the Pelican HSA 775 are to complete the Health Savings Account Enrollment and Payroll Deduction/Change Form each calendar year.  The form is attached.  An employee who elects to change his/her monthly deduction must also complete a new form.  This form must be turned into Human Resources.

 

Health Savings Account Enrollment and Payroll Deduction/Change Form

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