SABC Flexible Spending Cafeteria Plan, Direct Deposit Authorization Request

Choose the Appropriate Selection:
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)

Employee Name (First & Last)                                                    Daytime Phone

Employee Social Security Number or Employee Company Id

Company   Company

Employee Email Address for Notification (Required)


Employee Signature

(Please enter your 9 digit SSN or employee company id acknowledging you are authorizing this.)

Checking     Savings


Financial Institution Name

Financial Institution City and State

Financial Institution Routing/Transit (ABA) Number
Deposit Ticket numbers cannot be used.

Your Account Number

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