Fill - Free fillable Section 125 Flexible Benefit Plan Direct Deposit Form PDF form

F‐S125DD‐0418

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Section 125 Flexible Benefit Plan Direct

Deposit Form

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AuthorizationAgreementforAutomaticDeposits(ACHCredits)

EMPLOYEE INFORMATION(PleasePrint)

FIRSTNAME MI LASTNAME SSN

EMPLOYER   EMAILADDRESS

IherebyauthorizeFirstFinancialAdministrators,Inc.,hereinaftercalled“COMPANY”toinitiatecreditentriestomy

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(selectone) Checking Savings

accountandthedepositorynamedbelow,hereinaftercalled“DEPOSITORY”,tocreditthesamesuchaccount.

DEPOSITORY INFORMATION

DEPOSITORYNAME BRANCH

CITY STATE ZIP

VOIDED CHECK

PLEASE ATTACH AN ORIGINAL OR A COPY OF A VOIDED CHECK HERE.

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SUBMIT FORM AND VOIDED CHECK TO:

Attachyourvoidedcheckinthespaceallottedandmailbacktous.Itwilltakeapproximatelytwoweeksfromthedatethatwe

receivethisauthorizationfordirectdepositstobegin.

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MAIL:FirstFinancialAdministrators,Inc. FAX:800‐298‐7785

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P.O.Box161968‐OR‐

AltamonteSprings,FL32716

EMPLOYEE SIGNATURE(REQUIRED)

ThisauthorityistoremaininfullforceandeffectuntilCOMPANYhasreceivedwrittennotificationfrommeofit’sterminationin

suchtimeandinsuchmannerastoaffordCOMPANYandDEPOSITORYareasonableopportunitytoactonit.

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EMPLOYEESIGNATURE: DATE

FirstFinancialAdministrators,Inc.•POBox161968•AltamonteSprings,FL32716•Phone:800‐523‐8422•Fax:800‐298‐7785

Fill Online, Printable, Fillable, Blank Section 125 Flexible Benefit Plan Direct Deposit Form Form