FS125DD0418
Section 125 Flexible Benefit Plan Direct
Deposit Form
AuthorizationAgreementforAutomaticDeposits(ACHCredits)
EMPLOYEE INFORMATION(PleasePrint)
FIRSTNAME MI LASTNAME SSN
EMPLOYER  EMAILADDRESS
IherebyauthorizeFirstFinancialAdministrators,Inc.,hereinaftercalled“COMPANY”toinitiatecreditentriestomy
(selectone) Checking Savings
accountandthedepositorynamedbelow,hereinaftercalled“DEPOSITORY”,tocreditthesamesuchaccount.
DEPOSITORY INFORMATION
DEPOSITORYNAME BRANCH
CITY STATE ZIP
VOIDED CHECK
PLEASE ATTACH AN ORIGINAL OR A COPY OF A VOIDED CHECK HERE.
SUBMIT FORM AND VOIDED CHECK TO:
Attachyourvoidedcheckinthespaceallottedandmailbacktous.Itwilltakeapproximatelytwoweeksfromthedatethatwe
receivethisauthorizationfordirectdepositstobegin.
MAIL:FirstFinancialAdministrators,Inc. FAX:8002987785
P.O.Box161968‐OR
AltamonteSprings,FL32716
EMPLOYEE SIGNATURE(REQUIRED)
ThisauthorityistoremaininfullforceandeffectuntilCOMPANYhasreceivedwrittennotificationfrommeofit’sterminationin
suchtimeandinsuchmannerastoaffordCOMPANYandDEPOSITORYareasonableopportunitytoactonit.
EMPLOYEESIGNATURE: DATE
FirstFinancialAdministrators,Inc.POBox161968AltamonteSprings,FL32716Phone:8005238422Fax:8002987785
Chrome Web Store
It looks like you haven't installed the Fill Chrome Extension Add to Chrome