Minnesota Direct Deposit Form 3 - Free Download
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Rev: 06/2012
Eide Bailly Employee Benefits
U.S. Bancorp Center
800 Nicollet Mall, Suite 1350
Minneapolis, Minnesota 55402-7033
612-253-6633 ♦ 800-300-1672
Fax 612-253-6622
www.eidebaillybenefits.com/som
You have the option to receive your MDEA, DCEA, HRA and/or TEA reimbursements by direct deposit to your financial
institution. (If you received reimbursements via direct deposit last year, you do not need to complete this form.)
How does direct deposit work
When using direct deposit, your reimbursement will be deposited into your account on the scheduled reimbursement date.
Whether you are on vacation, sick, or traveling out of town, your reimbursements will automatically be deposited into the
specified account and available for your use.
How will I know the amount that has been deposited
You will receive a statement with a voided check showing the amount deposited in your bank account.
What do I need to do in order to sign up
Complete the information below and return it to Eide Bailly Employee Benefits. You may also enter your banking information
by logging into the secure Consumer Portal at www.eidebaillybenefits.com. Direct deposits will begin with your next
scheduled reimbursement after this form has been completed, received and processed by Eide Bailly. The direct deposit will
remain in effect until you rescind or change the authorization in writing.
What if I want my deposit made to my savings account
Ask your bank for the bank routing number and your savings account number and provide the information below.
Yes, I would like to receive my Pre-Tax Benefit reimbursements by direct deposit
Employer Name:
State Employee ID Number: _____ _____ _____ _____ _____ _____ _____ _____
First Name: MI: Last Name:
Home Address:
City: State: Zip:
Daytime Phone: ( )
FOR DIRECT DEPOSIT TO:
BANK NAME ________________________________________________________
Checking Account: Bank Routing Number _______________________________
Checking Account Number __________________________ OR
Savings Account: Bank Routing Number:
Savings Account Number:
By signing this form I agree to the accuracy of its contents and request to have any further deposits posted to the
above described bank account.
Employee Signature Date
STATE OF MINNESOTA
PRE-TAX DIRECT DEPOSIT FORM
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