When completed, mail, scan and email, or fax this form with voided check to:
Cafeteria Plan Company
PO Box 3684
Corrales, NM 87048
Fax: 505-247-0568 jwebb@rsabq.com
As an employee of the employer listed below and a participant in th is employer’s Cafeteria Plan and/or
Health Reimbursement Account , I (we) hereby authorize The Cafeteria Plan Company, hereinafter called "Company," to initiate credit entries to my Checking account _____________________ or my
Savings account _____________________ at the depository named below, hereinafter called
"Depository," to credit the same from such account.
Employer Name: ________________________________________________________________
Employee Name: ________________________________________________________________
Address: _______________________________________________________________________
City: ___________________________________ State: _____________Zip:_________________
Exact Name on Account: ___________________________________________________________
Depository (Bank) Name: __________________________________________________________
City __________________________________State: _____________________ Zip: ___________
Transit Routing Number: __________________________ Account Number:___________________
Printed Name of Account Signatory: __________________________________________
__________________________________________ _______________________
Signature Date
The routing number on your check is the first set of numbers on the bottom left -hand
and the account number is the next set of numbers. The third set of numbers is the check number that is reflected at the top of your check in the upper right-hand corner.
Please note: If you have previously received a direct deposit payment for a
Cafeteria Plan Claim, you do not need to re-submit your information unless your banking information has changed. Thank you.