AUTHORIZATION AGREEMENT FOR DIRECT DEPOSIT
OF FLEX SPENDING REIMBURSEMENTS
Company Name: _________________________
I hereby authorize BENEFIT RESOURCES to initiate deposit to the bank account indicated below. I
authorize credit entries and, if necessary, debit entries and adjustment for any credit entries made in error to
my account.
This account is: (Please check one of the following options)
New _______ Change_______ Cancel_________
_________________________ ____________________ __________________
Transit ABA Routing # Account Number Account Type
(Checking or Savings)
Name of Bank:_________________________________________________________________________
Bank Address:_________________________________________________________________________
_________________________________________________________________________
Bank Phone:__________________________________________________________________________
This authority is to remain in full force and effect until BENEFIT RESOURCES has received written notification
from me of its termination in such time and in such manner as to afford BENEFIT RESOURCES and
Depository a reasonable opportunity to act on it.
_________________________________________ _________________________
Please Print Your Name Social Security Number
_________________________________________ _________________________
Signature Date
Mail the completed form and a copy of a voided check (for checking accounts) or a deposit slip (for savings
accounts) to:
BENEFIT RESOURCES, INC.
4775 E. 91st Street, Suite 100
Tulsa, OK 74137-2805
Fax To: 918-481-6181 (Local Fax)
1-866-364-7052 (Toll Free Fax)
