Fillable Printable Automated Direct Deposit Authorization Agreement - Indiana

Automated Direct Deposit Authorization Agreement - Indiana

Name:

Phone:

( )

ABA Transit-Routing Number Title

Date Depository's Authorized Signature

, 19

(Number and Street, and/or P.O. Box No.) (City, State, and Zip Code (00000-0000)

Address:

Name of Depository:

Signature of Vendor / Claimant

SECTION 2: DEPOSITORY'S APPROVAL

The above is satisfactory and the undersigned designated depository agrees to accept such automated deposits.

, 19

Date

Depository Account Number:

Address (Number and Street, and/or P.O. Box No.) City, State, and Zip Code (00000-0000)

Type of Account:

Checking

(Demand)

Savings

It is understood by the undersigned Vendor/Claimant that, if approved, the Auditor of State may authorize the

Treasurer of State to: (1) initiate credit (deposits) in various and varying amounts, by electronic transfer of funds through

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

depository named below, and, (2) if necessary , to initiate debit entries or adjustments soley to correct any credit error

resulting from a deposit/credit entry that was made under this authorization . The Vendor/Claimant may revoke or cancel

this request and authorization by notifying the Auditor of State in writing at least fifteen (15) days prior. Any change to the

account or to a new financial institution will require a new State of Indiana Automated Direct Deposit Authorization

Agreement. Failure to timely notify the Auditor of an account change will delay payment.

requests, pursuant to IC 4-8.1-2-7(d), to receive payment(s) by means of an electronic transfer of funds, and authorizes the

same under the terms stated herein.

Name of Depository:

4. Requestor and depository should retain a copy. Additional blank copies are available from Auditor of State. Phone: (317) 232-3300

SECTION 1: REQUEST AND AUTHORIZATION

Instructions:

1. Requestor will complete first section and have their bank/credit union complete Section 2.

2. The bank/credit union will complete Section 2 and return to the requestor.

3. Requestor will file completed form with Auditor of State, 200 West Washington St., Room 240, Indianapolis, IN 46204-2728

STATE OF INDIANA

AUTOMATED DIRECT DEPOSIT AUTHORIZATION AGREEMENT

Name of Vendor/Claimant who prepared this Request

Work Number:

Home Number:

State Form 47551 (2/96)

Add Deposit Change Deposit Stop Deposit

Approved by State Board of Accounts 09/1997

Vendor / Claimant as shown on the account Federal I.D. Number / Social Security Number