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| Form Title: | Flexible Spending Direct Deposit Authorization (aka Election to Start or Stop Direct Deposit) |
| Last Revised: | 1/2007 |
| Purpose: | Allows direct deposit of reimbursements into the employee's designated account |
| Who Should Use the Form: | Employees contributing to Flexible Spending |
| Instructions: | Employee completes the form, signs and submits to PayFlex System USA, Inc., P. O. Box 3039, Omaha, NE 68103-3039 OR fax to 402-231-4310 (no cover page is required) |
| Form Download Information | |
| File Format: | Adobe Acrobat PDF (.pdf) |
| Download File: | Click Here to Download the Form |
| Problems? Contact: | Konnie Carrillo, x8706 |
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