ContentsReturn

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), P.O. BOX 14766, LEXINGTON, KY 40512-4766.

TYPE OF TRANSACTIONspacercheckbox  NEWspacercheckbox  CHANGEspacercheckbox  CANCEL


SECTION 1

TO BE COMPLETED BY EMPLOYEE
EMPLOYEE NAMEspacerLASTspacerFIRSTspacerMIDDLE INITIAL

TYPE OF ACCOUNT
spacercheckbox  CHECKING (attach a voided check to this form)spacercheckbox  SAVINGS (Your financial institution must complete section 2)
HOME ADDRESSspacerSTREETspacerCITYspacerSTATEspacerZIP CODE

WORK PHONEspacerAREA CODEspacerNUMBERspacerEXT.

HOME PHONEspacerAREA CODEspacerNUMBER

DEPARTMENT ID (5-DIGIT AGENCY CODE)

NYS EMPLID

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 _________________________________________________________spacerDATE ___/___/________

JOINT ACCOUNT HOLDERS CERTIFICATION
I CERTIFY THAT I HAVE READ AND UNDERSTAND THE INSTRUCTIONS FOR THIS FORM.

SIGNATURE _________________________________________________________spacerDATE ___/___/________


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)spacerCHECK DIGIT

ADDRESS OF FINANCIAL INSTITUTIONspacerSTREETspacerCITY

ACCOUNT TITLE

STATEspacerZIPspacerPHONE

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

__________________________________________ __________________________________________ ___/___/______