Fillable Printable Eft Direct Deposit Authorization Form - Colorado

Eft Direct Deposit Authorization Form - Colorado

EFT DIRECT DEPOSIT AUTHORIZATION FORM

State of Colorado Form Rev 5/2014

SECTION I – DEPOSITOR STATE AGENCY INFORMATION

RETURN THIS FORM TO:

STATE AGENCY ___________________________________________________________________________

MAILING ADDRESS _______________________________________________________________________

CITY, STATE, ZIP __________________________________________________________________________

AGENCY CONTACT __________________________________________________ PHONE _______________________________________

SECTION II – PAYEE (RECEIVOR) INFORMATION

VENDOR NAME _____________________________________________________________________________________________________

D/B/A ____________________________________________________________________________________________

MAILING ADDRESS _____________________________________________________________________________

CITY, STATE, ZIP ________________________________________________________________________________

PHONE __________________________________ EMAIL ______________________________________________________________

SECTION III – FINANCIAL INSTITUTION AND ACCOUNT INFORMATION

ATTACH AN ORIGINAL VOIDED CHECK (TEMPORARY CHECKS AND DEPOSITS SLIPS WILL NOT BE ACCEPTED) OR

A BANK LETTER. BANK LETTER MUST INCLUDE ALL INFORMATION REQUESTS IN SECTION III.

DEPOSITORY INSTITUTION NAME ___________________________________________________________________________

BRANCH LOCATION (CITY & STATE) _________________________________________________________________________

TRANSIT ABA NUMBER __ __ __ __ __ __ __ __ __

ACCOUNT # ____________________________________  CHECKING ACCOUNT  SAVINGS ACCOUNT

PAYEE SOCIAL SECURITY NUMBER ON BANK ACCOUNT __ __ __ - __ __ - __ __ __ __

PAYEE EMPLOYER IDENTIFICATION ON BANK ACCOUNT __ __ - __ __ __ __ __ __ __

FOR FURTHER CREDIT TO ACCOUNT ______________________________

SECTION IV – AUTHORIZATION FOR DIRECT DEPOSIT SETUP, CHANGE, OR CANCELLATION

 SET UP  CHANGE  CANCEL

I (we) certify I have the authority to execute this authorization. I (we) herby authorize the depositor named at the top of this form

to initiate, change or cancel EFT credit entries (deposits), and if necessary to reverse any incorrect EFT payments made in error to

the bank account indicated above. In the event a “reversal” can not be implemented, I (we) understand the state will utilize any other

lawful means to recover the deposited funds to which the payee was not entitled. I (we) and the depositor agree to be bound by

National Automated Clearing House Association (NACHA) Rules.

This authorization is to remain in full force until the State Depositor Agency named above has received written notification from me

of termination in such time as to afford a reasonable opportunity to act on it or until the record is inactive for two or more years and

is purged from the state payable system.

PRINTED NAME ___________________________________________________________ TITLE _________________________________________

Signature ______________________________________________ (your name here serves as an electronic signature) Date ____ / ____ / ____

(9 digit routing number)