Direct Deposit Enrollment



Company:
Employee Name:
Participant Id: ?
Email:
Phone:xxx-xxx-xxxx

Check Routing and Account Location

Routing #:Re-enter Routing #:
Account #:Re-enter Account #:

OR

Attach Scan of Check (Optional)
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I hereby authorize Allegiance Benefit Plan Management, Inc. to initiate credit entries and, if necessary, debit entries and adjustments for any credit entries in error to my account as indicated below and depository named below, hereinafter called BANK, to credit and/or debit the same such account. This authority is to remain in full force and effect until Allegiance Benefit Plan Management, Inc. has received written notification from me of its termination in such time and manner as to afford Allegiance Benefit Plan Management, Inc. and the BANK a reasonable opportunity to act on it. I understand this authorization is for reimbursements from my employer-sponsored flexible spending plan.





 

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