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Clear Form MAIL TO PayFlex Systems USA Inc. Flex Dept. P. O. Box 3039 Omaha NE 68103-3039 402 345-0666 FAX TO 402 231-4283 No Cover Page Required Page 1 of DIRECT DEPOSIT AUTHORIZATION FORM New Agreement Change Account Cancel Agreement I hereby authorize PayFlex Systems USA Inc. PayFlex to initiate credit or debit entries to my account with the Financial Institution indicated below. This authority is to remain in full force and effect until PayFlex has received written notification from me of...
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