EMPLOYEE NAME _____   _   _ 	_    _    _    _    _    _    _ _   _ 	__

TODAY’S DATE____ _ _ _ _

BANK NAME AND ADDRESS:

BANK ACCOUNT NUMBER:  	

CIRCLE ONE: CHECKING OR SAVING

AMOUNT TO BE DEPOSITED PER PAY PERIOD INTO HEALTH SAVINGS ACCOUNT $____ _ 	

PLEASE ATTACH A DEPOSIT SLIP FOR VERIFICATION OF BANK NUMBER

EMPLOYEE NAME _____   _   _ 	_    _    _    _    _    _    _ _   _ 	__

TODAY’S DATE____ _ _ _ _

BANK NAME AND ADDRESS:

BANK ACCOUNT NUMBER:  	

CIRCLE ONE: CHECKING OR SAVING

AMOUNT TO BE DEPOSITED PER PAY PERIOD INTO HEALTH SAVINGS ACCOUNT $____ _ 	

PLEASE ATTACH A DEPOSIT SLIP FOR VERIFICATION OF BANK NUMBER

EMPLOYEE NAME _____   _   _ 	_    _    _    _    _    _    _ _   _ 	__

TODAY’S DATE____ _ _ _ _

BANK NAME AND ADDRESS:

BANK ACCOUNT NUMBER:  	

CIRCLE ONE: CHECKING OR SAVING

AMOUNT TO BE DEPOSITED PER PAY PERIOD INTO HEALTH SAVINGS ACCOUNT $____ _ 	

PLEASE ATTACH A DEPOSIT SLIP FOR VERIFICATION OF BANK NUMBER

EMPLOYEE NAME _____   _   _ 	_    _    _    _    _    _    _ _   _ 	__

TODAY’S DATE____ _ _ _ _

BANK NAME AND ADDRESS:

BANK ACCOUNT NUMBER:  	

CIRCLE ONE: CHECKING OR SAVING

AMOUNT TO BE DEPOSITED PER PAY PERIOD INTO HEALTH SAVINGS ACCOUNT $____ _ 	

PLEASE ATTACH A DEPOSIT SLIP FOR VERIFICATION OF BANK NUMBER

EMPLOYEE NAME _____   _   _ 	_    _    _    _    _    _    _ _   _ 	__

TODAY’S DATE____ _ _ _ _

BANK NAME AND ADDRESS:

BANK ACCOUNT NUMBER:  	

CIRCLE ONE: CHECKING OR SAVING

AMOUNT TO BE DEPOSITED PER PAY PERIOD INTO HEALTH SAVINGS ACCOUNT $____ _ 	

PLEASE ATTACH A DEPOSIT SLIP FOR VERIFICATION OF BANK NUMBER

U.S. BANK: PLEASE ATTACH A VOIDED CHECK FOR VERIFICATION OF BANK NUMBER

EMPLOYEE NAME _____   _   _ 	_    _    _    _    _    _    _ _   _ 	__

TODAY’S DATE____ _ _ _ _

BANK NAME AND ADDRESS:

BANK ACCOUNT NUMBER:  	

CIRCLE ONE: CHECKING OR SAVING

AMOUNT TO BE DEPOSITED PER PAY PERIOD INTO HEALTH SAVINGS ACCOUNT $____ _ 	

PLEASE ATTACH A DEPOSIT SLIP FOR VERIFICATION OF BANK NUMBER

U.S. BANK: PLEASE ATTACH A VOIDED CHECK FOR VERIFICATION OF BANK NUMBER

EMPLOYEE NAME _____   _   _ 	_    _    _    _    _    _    _ _   _ 	__

TODAY’S DATE____ _ _ _ _

BANK NAME AND ADDRESS:

BANK ACCOUNT NUMBER:  	

CIRCLE ONE: CHECKING OR SAVING

AMOUNT TO BE DEPOSITED PER PAY PERIOD INTO HEALTH SAVINGS ACCOUNT $____ _ 	

PLEASE ATTACH A DEPOSIT SLIP FOR VERIFICATION OF BANK NUMBER

EMPLOYEE NAME _____   _   _ 	_    _    _    _    _    _    _ _   _ 	__

TODAY’S DATE____ _ _ _ _

BANK NAME AND ADDRESS:

BANK ACCOUNT NUMBER:  	

CIRCLE ONE: CHECKING OR SAVING

AMOUNT TO BE DEPOSITED PER PAY PERIOD INTO HEALTH SAVINGS ACCOUNT $____ _ 	

PLEASE ATTACH A DEPOSIT SLIP FOR VERIFICATION OF BANK NUMBER

EMPLOYEE NAME _____   _   _ 	_    _    _    _    _    _    _ _   _ 	__

TODAY’S DATE____ _ _ _ _

BANK NAME AND ADDRESS:

BANK ACCOUNT NUMBER:  	

CIRCLE ONE: CHECKING OR SAVING

AMOUNT TO BE DEPOSITED PER PAY PERIOD INTO HEALTH SAVINGS ACCOUNT $____ _ 	

PLEASE ATTACH A DEPOSIT SLIP FOR VERIFICATION OF BANK NUMBER

EMPLOYEE NAME _____   _   _ 	_    _    _    _    _    _    _ _   _ 	__

TODAY’S DATE____ _ _ _ _

BANK NAME AND ADDRESS:

BANK ACCOUNT NUMBER:  	

CIRCLE ONE: CHECKING OR SAVING

AMOUNT TO BE DEPOSITED PER PAY PERIOD INTO HEALTH SAVINGS ACCOUNT $____ _ 	

PLEASE ATTACH A DEPOSIT SLIP FOR VERIFICATION OF BANK NUMBER

EMPLOYEE NAME _____   _   _ 	_    _    _    _    _    _    _ _   _ 	__

TODAY’S DATE____ _ _ _ _

BANK NAME AND ADDRESS:

BANK ACCOUNT NUMBER:  	

CIRCLE ONE: CHECKING OR SAVING

AMOUNT TO BE DEPOSITED PER PAY PERIOD INTO HEALTH SAVINGS ACCOUNT $____ _ 	

PLEASE ATTACH A DEPOSIT SLIP FOR VERIFICATION OF BANK NUMBER

EMPLOYEE NAME _____   _   _ 	_ _ _ _ _ _ _ _ ___ __

TODAY’S DATE____ _ _ _ _

BANK NAME AND ADDRESS:

BANK ACCOUNT NUMBER:  	

CIRCLE ONE: CHECKING OR SAVING

AMOUNT TO BE DEPOSITED PER PAY PERIOD INTO HEALTH SAVINGS ACCOUNT $____ _ 	

PLEASE ATTACH A DEPOSIT SLIP FOR VERIFICATION OF BANK NUMBER