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I hereby authorize Allegiance Benefit Plan Management, Inc. to initiate credit entries and, if necessary, debit entries and adjustments for any credit
entries in error to my account as indicated below and depository named below, hereinafter called BANK, to credit and/or debit the same such account. This
authority is to remain in full force and effect until Allegiance Benefit Plan Management, Inc. has received written notification from me of its termination
in such time and manner as to afford Allegiance Benefit Plan Management, Inc. and the BANK a reasonable opportunity to act on it. I understand this
authorization is for reimbursements from my employer-sponsored flexible spending plan.
By clicking this box, I hereby certify that I am the person whose name appears above, and that my name as it appears above is
intended for purposes of this form to be my genuine signature and acknowledgement of this document.