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Get Wells Fargo Direct Deposit Form

Did you know you can provide your Direct Deposit information online Simply log in to the Wells Fargo Health Account Manager at www. Direct Deposit Form for Health Savings Account HSA Distributions Please use this form to enable Wells Fargo Health Benefit Services HBS to deposit distributions directly into your checking account or to change or cancel your direct deposit arrangement. I understand that by canceling my direct deposit I will receive my HSA reimbursements in the form of a check mailed to my primary mailing address. Signature of Account Holder Date Please Print Sign Fax to 888 824-3868 or mail to Wells Fargo Health Benefit Services P. An example of a Bank Routing Number RTN and Account Number is provided to the right. Deposit slips should not be used to obtain this information. Bank Routing Number 9 digits Checking Account Number New Bank Routing Number 9 digits New Checking Account Number Set Up Direct Deposit Change Direct Deposit I hereby authorize Wells Fargo HBS a division of Wells Fargo Bank N.A. I understand this request is effective from the time of receipt by Wells Fargo HBS. I acknowledge that this authorization is binding and is to remain in full force and effect until I notify Wells Fargo HBS of its termination in writing or by calling 1866-492-6434 in such time and in such manner as to allow Wells Fargo HBS and the depository financial institution a reasonable opportunity to act. I understand that by canceling my direct deposit I will receive my HSA reimbursements in the form of a check mailed to my primary mailing address. wellsfargo. com/hsa and provide your direct deposit information* Personal Information First Name Last Name M. I. Street Address City E-mail Address Optional Social Security XXX-XX-XXXX State Phone XXX-XXX-XXXX Zip Code Alternate Phone XXX-XXX-XXXX Employer Name if the HSA is offered through an employer otherwise write Individual Health Insurance Carrier/Insurance Provider Select an action from the options below. to directly deposit my HSA distributions to the account identified above. I understand that the notice of deposit is not a guarantee that funds have been received by my financial institution* I acknowledge that the origination of the ACH transfer to my account identified above must comply with the provisions of U*S* law. I understand this request is effective from the time of receipt by Wells Fargo HBS* I acknowledge that this authorization is binding and is to remain in full force and effect until I notify Wells Fargo HBS of its termination in writing or by calling 1866-492-6434 in such time and in such manner as to allow Wells Fargo HBS and the depository financial institution a reasonable opportunity to act. I understand that by canceling my direct deposit I will receive my HSA reimbursements in the form of a check mailed to my primary mailing address. Signature of Account Holder Date Please Print Sign Fax to 888 824-3868 or mail to Wells Fargo Health Benefit Services P. O. Box 413042 Salt Lake City UT 84141-3042 Questions Please contact our Customer Service Center at 866 890-8309.

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