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Health Savings Account Amendment Form 2022-2023
Click to view (pdf or doc)
Plan year July 1, 2022 through June 30, 2023
Use this form at any time during the year to start, stop, increase, or decrease the amount you contribute to you HSA.
Revision date: 04/25/2022
Submit paper form to Benefits Office, 112 Scovell Hall, Lexington KY 40506-0064
Email form back to email@example.com