SABC Flexible Spending Cafeteria Plan, Direct Deposit Authorization Request


Check the Appropriate Box


I an Employee of , authorize SABC to:

Initiate electronic credit entries from my Flexible Spending Cafeteria Plan account, based on each claim for reimbursement I submit to SABC, and if necessary, any debit entries and adjustments for any credit entries in error. I acknowledge and understand that it is my responsibility to check the account on the next business day, after receiving email notification of payment, to ensure that the account was properly credited. I understand that I am required to have an email account in order to be notified a payment was issued. I understand SABC will not be liable for any bank charges resulting from problems associated with payment by direct deposit such as: my error in providing the correct bank information, or my failure to notify SABC when a bank account is closed. If SABC is charged a fee, by any financial institution in regard to incorrect or closed account information due to failure on my part, SABC reserves the right to transfer those fees to me.

I acknowledge that the origination of an Automated Clearing House (ACH) transaction to my Checking Account must comply with the provisions of U.S. law. This authority will remain in effect until I have cancelled it by filing a new form with SABC.


(Please Complete All Fields)

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Employee Name   Daytime Phone


Employee Social Security Number


Employee Email Address for Notification (Required)


Date


Employee Signature

(Please enter your 9 digit SSN acknowledging you are authorizing this.)


Checking     Savings


Bank Information


Financial Institution Name


Financial Institution City and State


Financial Institution Routing/Transit (ABA) Number


Your Account Number

Please double check the FDIC Bank Routing/Transit and your bank account number for accurate entry.