Wabash Valley Online Application Consortium - HSA Employee Deduction Change
HSA Employee Deduction Change
Organization:
Wabash Valley Online Application Consortium
Assigned To:
Public User
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In 2026, West Lafayette Community School Corporation will fund the following HSA Contribution for employees who choose the High Deductible Health Plan:
$2,000 – Employee Only Insurance Plan
$3,000 – Employee Plus (all other plans - EE + Spouse, EE + Child(ren) and Family)
To make a change to the
employee's
contribution, please complete this form in its entirety. Employees are allowed to change their HSA deduction
once per quarter
.
Today's Date:
Today's Date: required
Amount to Deduct Per-Pay:
Amount to Deduct Per-Pay: required
Email Address:
Email Address: required
This authorization is to remain in full force and effect until WLCSC has received written notification from me of its termination in such time and in such manner as to afford WLCSC a reasonable opportunity to act on it.
Signing
Signature is required
By typing in your name (your “eSignature”), you accept and consent to be legally bound by this document’s statements, terms and conditions as if this document was signed by you in writing with pen on paper. You agree that no third party or other means of verification is necessary to validate your eSignature and that the lack of such third party or other means of verification will not in any way affect the enforceability of this document.
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History
Step:
Someone fills out the form
Sent To: Public User, On:
7/27/2026 7:09:07 AM Eastern Standard Time