Fillable Printable Ach Form for Direct Deposit Payments to Providers - Colorado

Ach Form for Direct Deposit Payments to Providers - Colorado

ACH FORM FOR COLORADO PROVIDERS

FOR DIRECT DEPOSIT PAYMENTS TO PROVIDERS

LCHS 3510 (2/15)

I (we) hereby authorize J.P. Morgan Electronic Financial Services, Inc. (JPMorgan EFS), as designated agent for the

Colorado Department of Human Services (CDHS), to initiate credit entries, and if necessary, reverse any incorrect

EFT credit entries made in error due to the bank account indicated below, in accordance with standard banking

procedures, for payments related to the Colorado Electronic Benefits Transfer (EBT) program.

County Use Only: - PROVIDER NUMBER REQUIRED

Child Care (CC)

Foster/Adoptive (CW)

Colo. Works, TANF, COIN (9digit)

LEAP (LE)

Nursing Home (NH)

CORE, CASE (CW3)

Name of County Staff completing this section:

Phone of County Staff (including Area Code)

Your Name:

Address:

City, State, Zip:

Telephone # (including area code):

( )

Federal E.I.N. #:

Social Security #:

CHECK HERE IF THIS IS A REQUEST TO CHANGE BANKING INFO PREVIOUSLY SUBMITTED:

If a change of banking information, what is the effective date of this change?

TYPE OF ACCOUNT: (Please check only one):

Checking (attach voided check)

Savings (attach voided deposit slip)

Account #:

Name of Bank:

Transit/Routing #:

(Please check with your bank to ensure this number is correct for direct deposit.)

Telephone # for Bank:

( )

This agreement is to remain in full force and effect until (JPMorgan EFS), as designated agent for CDHS, has

received written notofication from the vendor/provider of its termination in such time and manner to afford JPMorgan

EFS a reasonable opportunity to act on it. It is the responsibility of the vendor/provider to fill out and submit a new

Authorization Agreement to CDHS if the vendor/provider changes banks or accounts.

Provider Signature

Date

Please return this form to:

Accounting/Child Care

Larimer County DHS

2601 Midpoint Drive, Suite 112

Fort Collins, Colorado 80525