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P.O. Box 928 Findlay, OH 45839 6516952500 8004867664 Fax: 4194235834 www.ebsobenefits.com CREDIT AUTHORIZATION FORM MEDICAL REIMBURSEMENT/DEPENDENT CARE REIMBURSEMENT/HRA I hereby authorize ESO, Inc.

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Findlay OH 45839 is the zip code for the city of Findlay in Ohio.

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