Rev. 01/2013
AUTHORIZATION AGREEMENT
F
OR
D
IRECT DEPOSIT REIMBURSEMENT
(PLEASE PRINT CLEARLY)
Please Check One: Set up new Direct Deposit Change Direct Deposit Account Cancel Direct Deposit
EMPLOYEE INFORMATION
Employer Name:
Employee Member ID:
Last Name: First Name: MI:
Address:
City: State: Zip:
Phone Number:
BANK ACCOUNT INFORMATION
Account Type (please check one): Checking Account Savings Account
Name of Bank:
An empty block should indicate spaces between words.
Bank Routing #:
Account #:
(Please allow 14 days after receipt by Benefit Resource, Inc. for bank pre-notification to be completed.)
AUTHORIZATION AGREEMENT
I hereby authorize Benefit Resource, Inc. to initiate credit entries to the bank account indicated above and, if
necessary, to initiate debit entries and adjustment for any credit entries made in error to my account. This
authorization is to remain in full force and effect until Benefit Resource has received written notice from me of its
termination and has had a reasonable opportunity to act on it. I understand that this authorization cannot be processed
unless it is completed in full and returned to Benefit Resource. By authorizing any direct deposits, I certify that the
reimbursed expenses qualify for reimbursement under IRS regulations, are for a qualifying individual, and will not be
reimbursed from any other source.
Signature: ____________________________________________________ Date: ______/________/________
Please return completed form to Benefit Resource, Inc. Retain a copy for your files.
Internal Use Only: Initial and Date FSA/HRA ______________ CBP ______________
245 Kenneth Drive
Rochester NY 14623-4277
Phone: (800) 473-9595
Fax: (585) 697-0331
or
(585) 424-7273
www.BenefitResource.co
