Cafeteria Plan Company Authorization Agreement for

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Cafeteria Plan Company

Authorization Agreement for

Direct Deposit of your Cafeteria Plan Reimbursement

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 [email protected]

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.

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