Fillable Direct Debit & Credit Authorization Agreement

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Direct Debit & Credit Authorization Agreement

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The Direct Debit & Credit Authorization Agreement form is 1 page long and contains:

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  • 2 check-boxes
  • 17 other fields

Country of origin: OTHERS
File type: PDF

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Direct Debit & Credit Authorization Agreement
Navia Benefit Solutions ACH Company IDs – 3911467758, 1911467758
Avidia Bank ACH Company IDs (HSA) – 1383261866, 9383261866
Please select the purpose(s) of this direct debit authorization:
TYPE OF DEBIT AUTHORIZED
EFFECTIVE DATE
TYPICAL TIMELINE FOR DEBITS
FSA Payroll Deductions (Contributions)
______________
1 business day following posted contributions
FSA Claim Reimbursements (Disbursements)
______________
1 business day following reimbursements
HRA Claim Reimbursements
______________
1 business day following reimbursements
Administrative Fees (monthly invoicing)
______________
5 business days following the invoice date
Commuter
______________
23
rd
day of the month
HSA Contributions*
______________
Within 2 business days after submission
* Before HSA contribution debits can be initiated, a pre-note in the amount of $1.00 will be charged to verify your account.
I (we) hereby authorize Navia Benefit Solutions to initiate debit or credit entries at the financial institution
indicated below, hereinafter called DEPOSITORY, and to debit or credit the same to such account. I (we)
acknowledge that the origination of ACH transactions to this account must comply with the provisions of
U.S. law.
EMPLOYER USE ONLY
AUTHORIZATION AGREEMENT FOR DIRECT DEBITS & CREDITS
Client Name:
Federal ID Number:
Financial Institution Information
Branch:
City:
Specify Account Type: Checking Account
Savings Account
Account Number:
Routing
Number:
This
authorization is to remain in full force and effect until Navia Benefit Solutions has received
written
notification
of its termination in such time and in such manner as to afford Navia and DEPOSITORY
a
reasonable
opportunity to act on it.
Name:
Signature:
Date:
NOTE: ALL WRITTEN DEBIT OR CREDIT AUTHORIZATIONS MUST PROVIDE THAT THE RECEIVER MAY
REVOKE THE AUTHORIZATION ONLY BY NOTIFYING THE ORIGINATOR IN THE MANNER SPECIFIED IN THE
AUTHORIZATION AGREEMENT.
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Direct Debit & Credit Authorization Agreement

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Completed 1 October 2021

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