NYS Flex Spending Account Rapid Access Check Express - Enter the RACE

To enter the RACE, please read the instructions 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.

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SECTION 1
To Be Completed By Employee
EMPLOYEE NAME (FIRST, MI, LAST):
TYPE OF ACCOUNT:  checkbox CHECKING      checkbox  SAVINGS
ACCOUNT NUMBER:
EMPLOYEE ADDRESS:

 
I AM ENROLLED IN:
checkbox  DCAAccount
checkbox  HCSAccount
checkbox  BOTH
PHONE: (WORK)
(HOME)
SOCIAL SECURITY NUMBER:
DEPARTMENT ID/AGENCY CODE:
NYS DEPARTMENT/AGENCY:
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
To Be Completed Before Submitting to FBMC
NAME AND ADDRESS OF FINANCIAL INSTITUTION:
ROUTING NUMBER (9 DIGITS):                    CHECK DIGIT:
ACCOUNT TITLE:
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 REPRESENTATIVE'S NAME:

TELEPHONE                                        DATE:
SIGNATURE OF REPRESENTATIVE: