Health Savings Account Direct Deposit Form

I hereby authorize Promise Early Education Center, hereinafter called AGENCY, to initiate credit entries, if necessary, debit entries and adjustments for any credit entries in error to my account indicated below and the depository named below hereinafter called Depository to credit and or debit same to such account.

New Account:  Please complete this section to set up direct deposit to a new Health Savings Account

Depository Name :________________________________________________________________________

Routing Number: _______________________________Account Number:__________________________

Bi-Weekly Contribution Amount: ___________________

Changes to Existing Account:  Please complete this form to change the contribution amount for an existing Health Savings Account.

Depository Name:________________________________________________________________________

Current Bi-Weekly Contribution Amount: ___________ NEW Bi-Weekly Contribution Amount:___________

The authority is to remain in full force and effect until Agency and Depository has received written notification from me of its termination in such manner as to afford Agency and Depository a reasonable opportunity to act on it.

Employee Name: _______________________________________ Date:_________________________________

Employee Signature: __________________________________________________________________________