Name:

Last   First   MI

Employee ID #:

Campus
Address:

Department    Campus Choose one Bloomington Indianapolis East Fort Wayne Kokomo Northwest South Bend Southeast

Building    Room #

Home
Address:

Street

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Phone:

Home    Campus

Action Taken

By completing and submitting this form, I wish to make the following election for my Tax Saver Benefit (TSB) Plan reimbursement account(s). Choose one:

Initiate Direct Deposit

Change Account Designation for Direct Deposit

Terminate Direct Deposit*

* If terminating direct deposit, go to the Acknowledgement section; do not complete the Authorization Agreement for Direct Deposit section.

Authorization agreement for direct deposit

I hereby authorize The Nyhart Company to initiate deposit entries and any adjustments to correct errors to my CHECKING ACCOUNT or SAVINGS ACCOUNT (select one) indicated below and the Bank/Credit Union named below to debit same to such account.

BANK / CREDIT UNION

STREET

CITY    STATE State Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming   Alberta British Columbia Manitoba New Brunswick Newfoundland Northwest Territories Nova Scotia Nunavut Ontario Prince Edward Island Quebec Saskatchewan Yukon Territory   Not USA or Canada    ZIP

ROUTING NO.    Account No.

Check with your financial institution for questions regarding your routing or account number.

acknowledgement

I understand that this authority is to remain in effect until The Nyhart Company receives written notification from me of a change in such time and in such manner as to afford The Nyhart Company a reasonable opportunity to act on it.

Employee Signature __________________________________________ Date ________________

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Mail completed form to:

The Nyhart Company
Attn: Flex Claim Reimbursement
P.O. Box 80208
Indianapolis, IN 46280-0208

Or fax completed form to: (888) 887-9961 or (317) 803-7770
Customer service: (800) 284-8412