WageWorks - Employee

Answer the following questions to determine how much you can save with a health saving account (HSA):

Amount you will contribute to your HSA each year through payroll deductions:

Amount your employer will contribute to your HSA each year:

Amount that will be contributed to your HSA each year from other sources:

Amount you will withdraw from your HSA each year for eligible expenses:

Your federal tax rate:

Your state tax rate:

Number of years until you retire:

Expected annual return on your HSA investments:

	Estimated Tax Savings This Year:	Please answer all questions.
	Estimated HSA Funds at Retirement:	Please answer all questions.