Flexible Spending Accounts

Direct Deposit/Email Authorization

Social Security Number: ______________________________

Employer: _________________________________________________

Employee Name: _________________________________________________

Address: _________________________________________________

City-State-Zip: _________________________________________________

Work Phone No.: (__ __ __) __ __ __ - __ __ __ __ ext. __ __ __ __

Email Notices of Flexible Spending Account reimbursements:

Please send email notices of my Flexible Spending Account reimbursements by direct deposit and employee periodic statements to the following address:

I wish to receive my Flexible Spending Account reimbursements by Direct Deposit. I hereby authorize Application Software Inc. (ASI) to originate electronic credit transactions to my bank (or credit union or savings & loan) account indicated below and to credit the same to such account. If necessary, ASI may make deductions from my account for any payments credited to my account in error. This authority is to remain in full force and effect until ASI has received written notification from me of its termination in such time as to afford ASI and my bank a reasonable opportunity to act on it.

Your bank's name: ____________________________________________________

Bank's Routing #: __________________ Your Account #: __________________

Type of account: _______Checking ______Savings

Signature _____________________________________ Date___________

If you have any questions call 1-800-659-3035 or e-mail us at asi@asiflex.com.

Direct Deposit Account Verification

For new authorizations, please attach a void check or a copy of a check in this area so that we may verify your routing and account numbers. Send to:

P. O. Box 6044, Columbia MO 65205-6044

or

fax to (573) 874-0425