Fillable Printable Automated Direct Deposit Authorization Agreement - Indiana
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