Direct Deposit Request

Please complete this form and return it to National Benefit Services, LLC

IMPORTANT! Please attach a voided check with this form (not a deposit slip). Only for a savings account is a deposit slip acceptable. If you have Direct Deposit information on file it carries forward unless corrected or rescinded in writing by you.

NBS FSA Direct Deposit Request Form

Click the button above to open and download the form

Direct Deposit Request

Please complete this form and return it to National Benefit Services, LLC

NBS Health Care Expense Worksheet

Flexible Spending Account Claim Form