3863 (201708)

FLEXIBLE BENEFIT PLANBank Account Number Request—Authorization for Electronic Funds TransferThis form allows WageWorks to withdraw funds from the account indicated below for Monthly Administration Fees and your respective Plan Benefit(s) contributions/payments (Flexible Spending Accounts: FSA, HRA, and HSA).

Company Name

Employer EIN

EFT Contact Name

I hereby authorize WageWorks, Inc. to initial variable debit entries to my checking account:

o Yes

Indicated below and my financial institution named below to debit the same to such account.

Please debit my account for Plan Benefit(s) (check one):

o Plan Benefit Payments o Fees o Both

Name of Financial Institution

Branch City State

Bank Routing / ABA Number

Account Number

This authority will remain in full force and effect until WageWorks, Inc. has received written notification from me of its termination in such time and in such manner as to afford WageWorks, Inc. a reasonable opportunity to act on it.

Signature Date

Complete and return to:take care by WageWorks, Attn: Flex AdministrationFax: 877-220-3251Postal: 1850 W. Rio Salado Pkwy., Suite 100, Tempe, AZ 85281