flexible benefit plan...383 (201708) flexible benefit plan bank account number...
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3863 (201708)
FLEXIBLE BENEFIT PLANBank Account Number Request—Authorization for Electronic Funds TransferThis form allows WageWorks to withdraw funds from the account indicated below for Monthly Administration Fees and your respective Plan Benefit(s) contributions/payments (Flexible Spending Accounts: FSA, HRA, and HSA).
Company Name
Employer EIN
EFT Contact Name
I hereby authorize WageWorks, Inc. to initial variable debit entries to my checking account:
o Yes
Indicated below and my financial institution named below to debit the same to such account.
Please debit my account for Plan Benefit(s) (check one):
o Plan Benefit Payments o Fees o Both
Name of Financial Institution
Branch City State
Bank Routing / ABA Number
Account Number
This authority will remain in full force and effect until WageWorks, Inc. has received written notification from me of its termination in such time and in such manner as to afford WageWorks, Inc. a reasonable opportunity to act on it.
Signature Date
Complete and return to:take care by WageWorks, Attn: Flex AdministrationFax: 877-220-3251Postal: 1850 W. Rio Salado Pkwy., Suite 100, Tempe, AZ 85281