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HEALTH SAVINGS ACCOUNT CONTRIBUTION ELECTION FORM (PLEASE PRINT CLEARLY) Purpose: This form is only to be used after a CDP is elected: To elect new payroll deduction amounts for HSA contributions
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Anyone who is a resident of Virginia and is required to file a state tax return needs to fill out 1 - virginia form. This includes individuals who earned income in Virginia or had Virginia income tax withheld from their wages.
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