Post Disbursement Funding Authorization Form
Employer’s Name: ____________________________________
Finance Contact Name: _________________________ Phone: ________________
Finance Contact Email: ____________________________________
I authorize 24HourFlex to initiate ACH withdrawals and credits from this account to fund the
FSA/HRA/HSA plans. Funds will be withdrawn automatically for any FSA/HRA claims paid
out and for any HSA contributions. Funds will be credited for any refund or repayment:
____________________________________
ABA Transit Routing Number (9 digits)
____________________________________
Account Number
Steps you must complete:
Add 24HourFlex’s originator number: 1266100769 as an authorized drafter to your account.
Drafting Frequency:
24HourFlex should pull funding each business day during the week
____________________________________ __________________
Employer’s Signature
Date
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Name of Bank or Financial Institution
_________________________________________________________________
Address of Bank or Financial Institution
____________________________________ ___________________________
Bank Contact Name
Bank Contact Phone Number