Fillable Your HRA distributions may be deposited directly into (MidAmerica)

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Your HRA distributions may be deposited directly into (MidAmerica)

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HRA_DirectDepositForm 2017.0214
Your HRA distributions may be deposited directly into your account or joint account with your spouse at your bank or
other financial institution. To sign up, please complete this form, and return it to the address listed at the bottom.
Your Employer:
EMPLOYEE INFORMATION:
Name:
Social Security Number:
Street Address:
City, State Zip:
E-mail Address:
Phone Number:
AUTHORIZATION:
I authorize MidAmerica Administrative & Retirement Solutions to deposit my HRA claims directly into my account
until I give further written notice to MidAmerica. I understand that it may take up to 72 hours from the time
MidAmerica processes my payment for the funds to post to my designated bank account. Also, I grant MidAmerica the
right to correct any electronic funds transfer resulting from an erroneous overpayment by debiting my account to the
extent of such overpayment.
Your signature Date
Bank Account Information
Bank Name:
Bank Telephone Number:
Bank Address:
Account Type: (check one) Checking Savings
(Attach voided check) (Attach Bank Verification Letter)
Transit Routing Number Account Number
Type of transaction (check one):
New request for Direct Deposit
Change current Direct Deposit information
Cancel Direct Deposit
Submit completed form and attachments to:
MidAmerica Administrative & Retirement Solutions
Attn: HRA Admin
P.O. Box 24927
Lakeland, FL 33802
Fax: 863.577.4460
Health Reimbursement Arrangement
(HRA) Direct Deposit Form
Authorization for Direct Deposit
P.O. Box 24927 Lakeland, FL 33802
855.329.0095 ♦ Fax 863.577.4460 ♦ www.MyMidamerica.com
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Your HRA distributions may be deposited directly into (MidAmerica)

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Completed 28 July 2021

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