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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. Then take or mail this form to your Financial Institution. The Financial Institution will verify the information in SECTION 1 and complete SECTION 2. The completed form must be returned to FRINGE BENEFITS MANAGEMENT CO. (FBMC), ENROLLMENT PROCESSING, PO BOX 1878, TALLAHASSEE, FL 32302.
TYPE OF TRANSACTIONspacercheckbox  NEWspacercheckbox  CHANGEspacercheckbox  CANCEL

SECTION 1

TO BE COMPLETED BY EMPLOYEE
EMPLOYEE NAMEspacerLASTspacerFIRSTspacerMIDDLE INITIAL
TYPE OF ACCOUNT
spacercheckbox  CHECKINGspacercheckbox  SAVINGS
HOME ADDRESSspacerSTREETspacerCITYspacerSTATEspacerZIP CODE
WORK PHONEspacerAREA CODEspacerNUMBERspacerEXT.

 HOME PHONEspacerAREA CODEspacerNUMBER
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 _________________________________________________________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 FBMC
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 NYACH, 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
__________________________________________ __________________________________________ ___/___/______

2002