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Health Savings Account Amendment Form 2023-2024
Click to view (pdf or doc)
Plan year July 1, 2023 through June 30, 2024
Use this form at any time during the year to start, stop, increase, or decrease the amount you contribute to you HSA.
Revision date: 04/13/2023
Submit paper form to Benefits Office, 112 Scovell Hall, Lexington KY 40506-0064
Email form back to email@example.com