Form Fsa005 - Enrollment Form For Fsa Claims printable pdf download

Form Fsa005 - Enrollment Form For Fsa Claims

Flexible Spending Account

Direct Deposit

Enrollment Form for FSA Claims

Use this form to enroll in the Direct Deposit service for your Flexible Spending Account (FSA). With Direct Deposit, your FSA

reimbursements will be deposited electronically into your bank account rather than sent to you as paper checks. Use this form

if you are enrolling for the first time in Direct Deposit or if you are changing the account that will receive your reimbursements.

Instructions:

Required Information

Complete the Required Information section.

PLEASE PRINT

Complete the Direct Deposit Information section.

Name _________________________________________

Sign and date the bottom of the form.

Make a copy of this form and retain for your records.

Social Security No.

Return this form and supporting documentation to:

Address _______________________________________

Fax 585-654-3155

Mail

Paychex, Inc.

______________________________________________

Attn: Administrative Support

E-mail Address __________________________________

1175 John Street

West Henrietta, NY 14586

Employer Name _________________________________

New Account

Change Account

Direct Deposit Information

I authorize my employer to deposit my FSA reimbursements to the following bank account (select one):

Checking

Account Number _________________________________________

Savings

Account Number _________________________________________

Paychex Access Card

Last 4 digits on card

Attach one of the following (select one) and indicate the name of the bank.

Voided check (deposit slips are not accepted)

Bank letter or specification sheet

(See your local bank representative.)

Bank Name ________________________________________________

Attach a voided check here.

IMPORTANT: A voided check, bank letter, or specification sheet must be attached.

Authorization

Paychex Use Only

Entered by _________________

Approved by ________________

____________________________________________ Date

Date

/ _______

SIGNATURE

Client BIS ID ________________

For questions about completing this form, call Paychex Employee Services at 877-244-1771.

FSA005 10/07

Form Fsa005 - Enrollment Form For Fsa Claims

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