Fillable Direct Deposit Authorization Form printable pdf download

Direct Deposit Authorization Form

Download a blank fillable Direct Deposit Authorization Form in PDF format just by clicking the "DOWNLOAD PDF" button.

Open the file in any PDF-viewing software. Adobe Reader or any alternative for Windows or MacOS are required to access and complete fillable content.

Complete Direct Deposit Authorization Form with your personal data - all interactive fields are highlighted in places where you should type, access drop-down lists or select multiple-choice options.

Some fillable PDF-files have the option of saving the completed form that contains your own data for later use or sending it out straight away.

Fax Completed Form to: 1-855-803-4887

Direct Deposit/Electronic Fund

You may also mail a completed form to:

PayFlex Systems USA, Inc.,

Transfer (EFT) Authorization Form

Flex Dept., PO Box 3039, Omaha, NE 68103-3039

Telephone: 1-888-678-8242

For Reimbursement Accounts

WAIT! Did you know that you can enroll in direct deposit online? Log in to and select Financial Center.

Then click on Enroll in Direct Deposit.

New Agreement

Change Account

Cancel Agreement

By signing below, I hereby authorize PayFlex Systems USA, Inc. (PayFlex) to make electronic credit transactions to my financial institution listed below

for reimbursement from my employer-sponsored reimbursement account plan. I also authorize PayFlex to initiate debit entries, if necessary, for any

credit entries made in error. I also authorize and request the bank listed below to accept any debit or credit entries by PayFlex to such account and to

debit or credit same to such account.

This authorization will remain in full force and effect until PayFlex has received written notification from me of its termination and in such time and in such

manner as to afford a reasonable opportunity to act on it. To cancel or change this authorization, complete and sign this form indicating the required

action and return it to the address listed above.

In case of errors or if you have questions about your electronic transactions, call us at the number listed above or write us at the address listed above as

soon as you can. If you think your bank statement is wrong or if you need more information about a transaction listed on your statement, we must hear

from you no later than 60 days after the FIRST bank statement on which the problem or error appeared.

Select One:

Checking Account

Savings Account

Financial Institution

Name

Branch

City

State

ZIP Code

Transit/ABA Number (See example below)