130_EFT_0812
PacificSource.com/PSA
PO Box 2797
Portland, OR 97208-2797
Phone (541) 485-7488 (800) 422-7038
FAX (866) 446-6090
Pacificsource.com/PSA
Authorization for
Electronic Funds
Transfer (EFT) / Direct
Deposit
EMPLOYEE INFORMATION
_____
Employer
Employee Last Name First Name Middle Initial 11-digit Member ID Number
ACCOUNT INFORMATION
Please check one of the following:
ADD Deposit my reimbursement funds to the account shown.
CHANGE Change my financial institution and/or account number.
CANCEL Stop my participation in the direct deposit program.
Type of account: Checking Savings
(If neither is marked, we will deposit to your checking account.)
I hereby authorize PacificSource Administrators to initiate deposits to the bank account
indicated below. I authorize credit entries and, if necessary, debit entries or adjustments for any
credit entries made in error to my account. This authority will remain in effect until PacificSource
Administrators has received written notification from me of its termination in a manner that
allows PacificSource Administrators a reasonable opportunity to act upon it. I understand that
PacificSource Administrators will not provide written statements advising me of
deposits. I have read and understand the information on the reverse side of this form.
Signature Date:
ATTACH VOIDED CHECK BELOW
Please tape your voided check here.
(Do not send deposit slips.)
Please mail completed form to PacificSource Administrators at the address above, or fax a copy
to (866) 446-6090. (Decorated checks and security watermarks can sometimes distort or hide
the account numbers when faxed.) Allow 10 working days for processing of this authorization.
You will receive regular reimbursement checks until this request is processed.
Important Information Regarding EFT/Direct Deposit Reimbursement
(Please read before signing Authorization Agreement form.)
Participants who wish to have their reimbursement checks deposited directly into their bank
account must complete an Authorization Agreement for EFT/Direct Deposit Form and mail it
to PacificSource Administrators with their voided check.
If you are currently enrolled in an FSA, HRA, and/or Transportation Plan, the information will
be entered and there will be a 10-day waiting period from the time PSA receives the
authorization until it takes effect.
If you are a new enrollee in an FSA, HRA, and/or Transportation Plan, your EFT information
will be added after we receive and process your enrollment information. The 10-day waiting
period begins the day you are entered into our system. Physical checks will be issued during
that time. Claims will not be held for direct deposit.
Once you agree to the EFT/Direct Deposit process, all reimbursement transactions will be in
this format until we receive your written request to cancel the process.
No written notice of EFT/Direct Deposits will be sent.
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