DR 0810 (07/18/13) 
COLORADO DEPARTMENT OF REVENUE                                           *130810==19999*
Denver, CO  80261-0005

                                  Employees Election Regarding
                                  Medical Savings Account

Employee's Last Name              First Name                             Middle Initial SSN

Employer's Name

Employer's Address                City                                                     State Zip

Account Administrator's Last Name First Name                                               Middle Initial

Account Administrator's Address   City                                                     State Zip

I hereby certify that I am an employee of the above listed employer who has offered to establish a medical savings 
account in my name with the above listed account administrator in accordance with §39-22-504.7, C.R.S.; or that my 
employer has not offered to establish such an account but I have established such an account with the above listed 
account administrator.
I hereby elect to have my contributions to such account, not to exceed $3,000 in any one calendar year, whether paid 
by my employer, withheld from my wages and paid to the account administrator by my employer, or paid directly to the 
account administrator by myself, to be made on a Colorado pre-tax basis.
Amounts may be distributed from a medical savings account only for the purpose of: reimbursing the eligible medical 
expenses of the account holder, his or her spouse or dependent children; cashing out the balance in the account of a 
deceased holder; or cashing out an account holder's prior years' balance.
This election and agreement shall continue in effect until canceled by myself or by the account administrator. I hereby 
acknowledge that I understand that any amounts withdrawn from my account for any purpose other than the payment of 
medical expenses of myself, my spouse, or my dependent children will constitute Colorado taxable income for myself or 
my estate, as the case may be.
Signature                                                                Date (MM/DD/YY)