NEUBRIDG INITIATED PERIODIC ACH REQUEST Ver:Jot121620.1

NEUBRIDG INITIATED PERIODIC ACH REQUEST

Ver Jot122923.1
Company Name* (Company) hereby authorizes NeuBridg, Inc. to initiate debit/credit entries to the Originating Depository Financial Institution (Section 1) account shown on the NEUBRIDG, INC. INITIATED ACH MASTER BANKING AGREEMENT form for the following payroll period.
SUBMISSION FOR PAYROLL PERIOD
Week Ending Date

MonthDayYear
MM/DD/YYYY Format
- OR -
Month Ending Date
MM/YYYY Format
NOTE: If the form is received before 3:00 PM CST, the funds will be withdrawn from your account on the next banking day. ALL documents received after 3:00 PM CST shall be processed the following business day, and withdrawal of funds shall occur on the date which complies with the bank’s ACH guidelines. Ample time is required to process all ACH requests, so there is no guarantee of the exact date of withdrawal.

SUB Plan Contributions

	Prevailing Wage	Non Previaling Wage	Total
SUB Plan
TOTAL

HRA Contributions

	Prevailing Wage HRA	Non-Prevailing Wage HRA	TOTAL
Health Reimbursment Account
TOTAL

Lifestyle Savings Account Contributions

	Prevailing Wage LSA	Non-Prevailing Wage LSA	TOTAL
Lifestyle Savings Account
TOTAL

Vacation & Holiday Plan Contributions

	Prevailing Wage HRA	Non-Prevailing Wage HRA	TOTAL
Vacation & Holiday Plan
TOTAL

SUMMARY OF CONTRIBUTIONS*

	Total
SUB Contribution Amount
HRA Contribution Amount
LSA Contribution Amount
VHP Contribution Amount
Sub-Total of Contributions
TOTAL APPROVED AMOUNT (Includes ACH Fee)

NEUBRIDG INITIATED PERIODIC ACH REQUEST