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k:; A�a a11510 <br />REIMBURSEMENT SERVICES AGREEMENT <br />Employer: County of Jefferson <br />Federal ID: 91-6001322 <br />Employer selects the following flex benefits checked below: <br />Medical Care Expense Reimbursement (URM) [ ] Commuter Parking & Transit (CSA) <br />('Dependent Day Care (DDC) [ ] Health Savings Account (HSA) <br />Employer elects FREE Flex Debit Card Services and agrees to the terms in Appendix E: VYes [] No <br />Employer elects URM Grace Period services and agrees to the terms in Appendix F: VYes [ ] No <br />J <br />Employer elects DDC Grace Period services and agrees to the terms in Appendix F: [�Y' es [ J No <br />Employer elects one Benefit Funding Method checked below and agrees to the respective terms in Appendix D: <br />[ ] 1-Daily ACH Debit* [ ] 2-Daily Client Bank Settlement �3-Fast Forward <br />*Daily ACH Debit funding is easiest to use for most employers <br />Employer Bank Account Information <br />Payments for FEES and BENEFIT FUNDS are pulled via WageWorks' initiated ACH debit, except for many Public Sector employers <br />(some schools and governmental entities) where electronic access to an employer's bank account by an unrelated third party service <br />provider for the collection of FEES and/or BENEFIT FUNDS is not permitted by law. <br />Fee Payments <br />Benefit Funding Payments <br />Applies to processing service fees <br />Same as Fee Payments <br />Name of Bank <br />Bank Routing Number (9 digits) <br />Bank Account Number: <br />Name of Employer's <br />1�1fz I l!t/IvS <br />Bookkeeping/Finance contact <br />ANA kff°x <br />Email: Bookkeeping/Finance contact <br />i-c"eeeje lei-wa,a <br />Kist D X u e �M t <br />Phone: Bookkeeping/Finance contact <br />392. q ZZ <br />Employer is a Public Sector entity <br />[ ] Check only if ACH debit to pull fees is <br />[ ] Check only if ACH debit to pull benefit <br />not permitted by law (and do not complete <br />funds is not permitted by law (and do not <br />above) <br />complete above) <br />ACKNOWLEDGEMENT. EXECUTION AND AGREEMENT <br />By signing below, you acknowledge (i) that you have the authority to bind the Employer named above to all terms, conditions <br />and obligations identified or set forth on the following pages in this Reimbursement Services Agreement and in Exhibit A (the <br />"Agreement") as of February 1, 2013 ("Effective Date") for the Plan Year beginning February 1, 2013 ("Initial Plan Year"); and <br />(ii) that you have read and understand the Agreement. Signing binds the Employer named above to all provisions of the <br />Agreement. /�,� <br />Employer: ��E,�SD�I r�fTl�L/t/Z�f WageWorks, Inc. <br />By: <br />Print Sign s Name: <br />Title: <br />Date: <br />A4,v ,'S�r'-�o 0 — <br />Miles S. Ross <br />Senior Vice President <br />New Client RSA <br />