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NYS FLEX SPENDING ACCOUNT Rapid Access Check Express Enter the RACE

TO ENTER THE RACE, PLEASE READ THE INSTRUCTIONS FOR THIS AUTHORIZATION FORM AND FILL IN THE INFORMATION REQUESTED IN SECTION 1. IF YOU CHOOSE TO DIRECT DEPOSIT YOUR REIMBURSEMENTS INTO YOUR SAVINGS ACCOUNT YOU MUST TAKE OR MAIL THIS FORM TO YOUR FINANCIAL INSTITUTION TO COMPLETE SECTION 2. RETURN THE COMPLETED FORM TO FRINGE BENEFITS MANAGEMENT COMPANY, A DIVISION OF WAGEWORKS (FBWW), ENROLLMENT PROCESSING, PO BOX 1878, TALLAHASSEE, FLORIDA 32302.

TYPE OF TRANSACTION  NEW  CHANGE  CANCEL SECTION 1 TO BE COMPLETED BY EMPLOYEE

EMPLOYEE NAMELASTFIRSTMIDDLE INITIAL TYPE OF ACCOUNT   CHECKING (attach a voided check to this form)  SAVINGS (Your financial institution must complete section 2) HOME ADDRESSSTREETCITYSTATEZIP CODE WORK PHONEAREA CODENUMBEREXT. HOME PHONEAREA CODENUMBER DEPARTMENT ID (5-DIGIT AGENCY CODE) SOCIAL SECURITY NUMBER NYS DEPARTMENT/AGENCY (EX: DOT, DEPT. OF HEALTH, TAX & FINANCE, ETC)

DEPOSITOR CERTIFICATION I CERTIFY THAT I HAVE READ AND UNDERSTAND THE INSTRUCTIONS FOR THIS FORM. IN SIGNING THIS FORM, I AUTHORIZE MY NYS FLEX SPENDING ACCOUNT REIMBURSEMENTS TO BE SENT TO THE FINANCIAL INSTITUTION NAMED BELOW, TO BE DEPOSITED TO THE DESIGNATED ACCOUNT. SIGNATURE _________________________________________________________DATE ___/___/________ JOINT ACCOUNT HOLDERS CERTIFICATION I CERTIFY THAT I HAVE READ AND UNDERSTAND THE INSTRUCTIONS FOR THIS FORM. SIGNATURE _________________________________________________________DATE ___/___/________ SECTION 2 FOR SAVING ACCOUNT DEPOSITS ONLY; TO BE COMPLETED BY YOUR FINANCIAL INSTITUTION BEFORE SUBMITTING TO FBWW

NAME OF FINANCIAL INSTITUTION ROUTING NUMBER (9 DIGITS)CHECK DIGIT ADDRESS OF FINANCIAL INSTITUTIONSTREETCITY ACCOUNT TITLE STATEZIPPHONE ACCOUNT NUMBER

FINANCIAL INSTITUTION CERTIFICATION I CONFIRM THE IDENTITY OF THE ABOVE-NAMED EMPLOYEE AND JOINT TENANT, IF ANY, AND THE ACCOUNT NUMBER AND TITLE. AS A REPRESENTATIVE OF THE ABOVE-NAMED FINANCIAL INSTITUTION, I CERTIFY THAT AS A MEMBER OF THE ACH, THIS FINANCIAL INSTITUTION AGREES TO RECEIVE AND DEPOSIT NYS FLEX SPENDING ACCOUNT REIMBURSEMENTS TO THE ACCOUNT SHOWN ABOVE, IN ACCORDANCE WITH THE POLICIES OF THIS FINANCIAL INSTITUTION.

PRINT OR TYPE REPRESENATIVE'S NAME SIGNATURE OF REPRESENTATIVE DATE __________________________________________ __________________________________________ ___/___/______