Employee Authorization for Direct Deposit
Complete this form to start or change direct deposit for your FSA or HRA.
Please check one of the boxes below (allow 1-2 pay periods for processing):
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Add: Please deposit my reimbursements into the bank account listed below.
Change: I would like to change the bank account where my current direct deposit reimbursement is sent.
Employer Name
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Employee Name
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First Name
Last Name
Employee CHRIS ID Number
*
Social Security Number
*
Employee Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Financial Institution
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Branch
Bank Routing Number (9 digits)
*
Select Account Type
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Checking Account
Savings Account
Account Number
*
I hereby authorize Custom Design Benefits, Inc. to initiate credit entries to the checking account indicated on this form as the depository financial institution for transactions related to my Flexible Spending Account or Health Reimbursement Account. Additionally, I authorize the Company to initiate any necessary debit reversal entries only for the correction of erroneous or duplicate entries previously credited to my account indicated on this form. It is acknowledged that the origination of ACH transactions to my account must comply with the provisions of United States law. This authorization is to remain in full force and effect until Custom Design Benefits, Inc. has received written notice of its termination in such time and in such manner to afford Custom Design Benefits, Inc. and the financial institution a reasonable opportunity to act on it.
Signature
*
Date
*
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Month
-
Day
Year
Date
For assistance, call 800.598.2929 or (for local Cincinnati area) 513.598.2929 or email CustomFlex@customdesignbenefits.com.
To view claims and other account information visit www.CustomDesignBenefits.com,click Member Portal, then Custom Flex: FSA/HRA/HSA.
Name
First Name
Last Name
Submit
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