Direct Deposit Enrollment Form

Please provide the information requested. Any incomplete or partially completed forms cannot

be processed and may delay payment. If you have questions, please call the NEON Finance

Department at 1-800-237-6828.

Section 1: Select an account

I want my FSS payments deposited into ONE of the following accounts:

Select One:

Checking – Attach copy of a voided check: REQUIRED

Savings

Pre-paid credit or debit card*

Section 2: Deposit Information

Name of Bank ______________________________________________

Routing Number* ______________________________________________

Account Number* ______________________________________________

Copy of a voided check REQUIRED for checking accounts

* Please note: Routing and account numbers are NOT located on pre- paid credit or

debit cards. You will need to call the customer service number on the back of your

card to obtain the routing and account numbers.

Section 3: Demographic Information

Print Name __________________________________________

Social Security Number _______ - _____- _________

Street Address ___________________________________________

City, State, Zip Code _____________________________________________

Phone Number (to reach you if there is a problem or question)_________________________

E Mail ____________________________________

Section 4: Authorization to Deposit Funds

I hereby authorize NEON to initiate credit entries to my account indicated above and PNC Bank

to credit the same to such account.

_______________________________________ _____________________

Signature Date

This form should be returned to the North East Ohio Network by mail, email or fax.

Address: 5121 Mahoning Ave, Austintown Ohio 44515

Email: cuy[email protected] Fax: 855-'‐336-'‐6968

Fillable Printable Direct Deposit Enrollment Form - Ohio