Fillable Printable Automated Direct Deposit Authorization Agreement Form - Indiana

Automated Direct Deposit Authorization Agreement Form - Indiana

Indiana law (I.C. 4-13-2-14.8) requires that YOU receive PAYMENT(S) by means of electronic transfer of funds.

This form must be accompanied by a W9.

Please print clearly and legibly in blue or black ink.

See Instructions on Reverse.

SECTION 1: AUTHORIZATION

According to Indiana law, your signature below authorizes the transfer of electronic funds under the following terms:

Printed Name (as shown on the account) Federal Identification Num ber / Social Security Number

Address (Number and Street, and/or PO Box Number) City, State, and ZIP Code ( 00000-0000)

SECTION 2: FINANCIAL INSTITUTION’S APPROVAL

Add Deposit Chang e D epo sit (prior information: ___________________________________ ____________________)

Please check this box if your direct deposit will be automatic ally for w arded to a bank account in another country.

Type of Account: Checking (Demand) Savings

ATTACH A NON-ALTERED VOIDED CHECK HERE.

(You must either attach a non-altered, matching voided ch eck or have your financia l institution complete this section.)

The financial institution identified below agrees to accept automated deposits under the terms set forth herein:

Name of Financial Institution: _______________________________ Telephone: ( )______________________________

Address: _

Number and Str eet, and/or P.O. Box Num b er City, State, and ZIP Code (00000-0000)

_____

, 20 _

Date (month, day) Financial Institution’s Authorized Signature / Title

ABA Transit-Routing Number Account Number

ATTACH A NON-ALTERED VOIDED CHECK HERE.

SECTION 3: ELECTRONIC NOTIFICATION OF ELECTRONIC FUND TRANSFER (EFT) DEPOSITS

(Complete this section only if you are requesting electronic notification. You may provide up to four email addresses.)

I hereby request that all future notices of EFT deposits to the bank account specified above be sent to the following email addresses:

__________________________________________________ __________________________________________________

________________________________________________ ________________________________________________

I agree to the provisions contained on the reverse side of this form.

NAME (print or type) __________________________ ___________________ TITLE_____________ ________ TELEPHONE______________________

AUTHORIZED SIGNATURE _________________ _____________________ _____________________ DATE (month, day, year) ________ _______

AUTOMATED DI RECT DEPOSIT

AUTHORIZATION AGREEMENT

State Form 47551 (R5 / 4-14)

Appro ved by State Board of Accounts, 2014

Approved by Auditor of State, 2014

INSTRUCTIONS:

1. Complete Section 1 and 3,and sign and date the bottom of the form.

2. Have your financial institution complete Section 2 and return it to you OR attach a pre-printed,

matching, non-altered voided check.

3. File the completed form with the agency that you do business with.

4. Retain a copy of the completed form for your records.

By Signing This Form:

You are responsible for insuring that this form was approved and instructions above are followed. By signing

this form, you represent that it is understood by all parties that, if approved:

1. The State of Indiana must initiate credits (deposits) in various amounts, by electronic transfer of funds

through automated clearing house (ACH) processes, to the listed checking (demand) or savings account

designated in the financial institution named in Section 2.

2. If necessary, you will accept reversals from the State for any credit entries made in error to the bank account

per National Automated Clearing House Association (NACHA) regulations.

3. You may only revoke this request and authorization by notifying the Auditor of State in writing, at the

following address at least fifteen (15) days before the effective date of revocation:

Indiana State Auditor, 200 W Washington St. Ste 240, Indianapolis, IN 46204.

4. Any change to the account or to a new financial institution will require a new State of Indiana Automatic

Direct Deposit Authorization Agreement. Failure to timely notify the Auditor of State of an account change

will delay payment.

5. The State of Indiana and its entities are not liable for late payment penalties or interest if you fail to provide

information necessary for an electronic funds transfer and/or you do not properly follow the Instructions above.

6. Complete Section 3: Electronic Notification of Electronic Fund Transfer (EFT) Deposits, only if you choose

to receive electronic EFT notifications by email. If this section is not complete, your notification will be sent by

US Mail to the remit address designated on the reverse side of this form.

7. The email address(es) provided in Section 3 for electronic EFT notification will allow for appropriate

application of all payments.

8. You acknowledge that it will cause disruption to the notification process if the email addresses provided for

electronic funds transfer notification are frequently changed or changed without promptly providing an updated

email address to the Auditor.

9. You acknowledge that an email notification returned as undeliverable may be removed from the Auditors

email notification system and all future notices of EFT deposits to you will be provided by the Auditor via US

Mail to the remit address designated on the reverse side of this form until you have provided a valid email

address to the Auditor.

10. You are responsible for contacting the Auditor of State’s office if you are not receiving electronic notices of

EFT deposits.