<p>Contact or Funding Change Notification</p><p>Use this form to notify us of a change in contact information or to add a bank account for plan funding.</p><p>SECTION A – GENERAL INFORMATION </p><p>1. Employer Name: </p><p>2. Federal Tax ID Number (EIN): </p><p>3. Change Effective Date: / / </p><p>Section B – NEW CONTACT Information N/A</p><p>1. Name: </p><p>2. Direct Phone Number: </p><p>3. Email Address: </p><p>Setup/Re-enrollment 4. Type of Contact (Select all that apply): Day-to-Day Billing</p><p>5. Online Access Needed to CS Employer Portal: Yes No</p><p>6. Replacement Contact: Yes, this contact has replaced (Name): No, this is an additional contact</p><p>SECTION C – EMPLOYER SIGNATURE For officer or department leader use only; Must currently be listed as an authorized contact at the employer group.</p><p>By signing below, I approve the information obtained within this document for purpose of changing a plan contact and/or funding account.</p><p>Employer Signature Date / / </p><p>Fifth Third CDH Contact or Funding Change Notification (CN1) v4.17</p>