Direct Deposit

First name *

Last name *

Employee SSN:
(Last 4 SSN ONLY) *

Employer *

Email address
*By providing your email address, you authorize Flexbene to electronically provide direct deposit notifications* *

Effective date * +

Name of Financial Institution *

Routing number *

Account number *

Account type *

Savings

Checking

Authorization

Authorization *

I hereby authorize Flexbene to initiate credit entries and, if necessary, debit entries to reverse erroneous credits, to my account indicated above. This authorization shall remain in full force and effect until Flexbene has received written notification from me of its termination in a timely manner as to afford Flexbene and the financial institution a reasonable opportunity to act upon it OR until I no longer participate in flexible benefits plan for a period of 6 months.

E-Signature (Provide Your FULL NAME & TODAYS DATE) *

Signature

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