Agmt14 Flex-Plan Services, Inc. - Laserfiche WebLink

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_ _. ....,r.�._ _ _� ._ �� � �� : ��,��.. �� ,� �� : _.. �,,._. . , , �L��x11"�� SERVI�ES]NCORP{}I2ATED Direct Debit & Credit Authorization Agreement Flex-Plan Services ACH Company IDs— 3911467758, 1911467758 Med-I-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 reimbursements FSA Claim Reimbursements(Disbursements) 1 business day following reimbursements HRA Claim Reimbursements 1 business day following reimbursements Administrative Fees(monthly invoicing) 1 S�Wednesday following the 15"' Commuter 23�'day of the month HSA Contributions' Within 2 business days after submission "Before HSA contrlbutlon debits can be lnitiated,a pre-note ln d�e amount of$1.00 Is sent to verffy your accounx AUTHORIZATION AGREEMENT FOR DIRECT DEBITS&CREDITS Client Name: Federal ID Number: I (we) hereby authorize Flex-Plan Services, Inc.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. Financial Institution Information Name: Branch: City: State: Zip: Specify Account Type: ❑Checking Account ❑Savings Account Account Number: Routing Number: This authorization is to remain in full force and effect until Flex-Plan Services has received written notification of its termination in such time and in such manner as to afford Flex-Plan Services and DEPOSITORY a reasonable opportunity to act on it. Name: Signature: Date: NOTE: ALL WRITI'EN 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. ATTY/AGR.2014.141/Flex-Plan Senrices, Inc.