Fillable Printable Form 120-212-000
Fillable Printable Form 120-212-000
Form 120-212-000
F120-212-000 Legal Representative Payment M ethod Authorizat ion 05-2017
Return completed forms to:
PO Box 44834
Olympia WA 98504-4834
Legal Representati ve Payment
Method Aut hor ization F or m
Fax: 360-902-4674Questions? Call toll free 844-728-5204 or 360-902-4675 or
Email: [email protected].gov
What can I use this form for?
Use this form to request a newpayment method or change the payment method for the clientsyou represent.
You can only select one payment method per form; however, you can update multiple claims using one form.
If you attach additional sheets, please type your list or print clearly. Please write your bank name and account
number at the top and sign the additional sheets.
Who can complete this form?
Only authorized representatives, as documented in your Articlesof Incorporation, PartnershipAgreement or
bank resolution, are allowed to sign this form. You will need to attach copies of yourArticles of Incorporation,
Partnership Agreement or bank resolutionfor verification.
When will my direct deposit start?
It can take up to 30 business days for a direct deposit requestto process.
Direct Deposit Limitations:
L&I can only make direct deposits into banks in the United States and US territories. Deposits for Legal
Representatives must be to IOLTA bank accounts.
L&I cannotmake direct deposits to time-loss alternate recipients due to system limitations.
How will I know my Direct Depositpayment method request is accepted?
Your receipt of payment into your bank account is your notification of paymentmethod acceptance.
If we are unable toprocess your form, you will be notifiedby phone or email.
Still have questions about how to complete this form?
Call toll free 844-728-5204 or 360-902-4675or email [email protected]
.
Want to reduce your mail from L&I?
Check out www.Lni.wa.gov/eCorrespondence
to see if you are eligible for e-Correspondence.
Please keep a copy of this form for your records.
F120-212-000 Legal Representative Payment M ethod Authorizat ion 05-2017
Return completed form to:
PO Box 44834
Olympia WA 98504-4834
Legal Representati ve Payment
Method Aut hor ization F or m
Fax: 360-902-4674Questions? Call toll free 844-728-5204 or 360-902-4675 or
Email: [email protected].gov
Please print clearly using blue or black in k. F i ll out this form completel y and sign.
Your information(All fields are required unless otherwise noted.)
Legal Group Name
Phone Number (include area code)
Fax Number (include area code)
Contact Name
Email address (optional)
Mailing Address
City State Zip Code
I wantdirect deposit for my payments.
Bank Name
Routing Number
Bank Account Number
I want to receive a paper check for my payments.
List all claim or folio numbers and the recipient names. Attach additional sheets if necessary. Pleasewrite your
bankname and account number at the top and sign the additional sheets.
This payment method is for:
Claim or Folio Number
Recipient Name
Claim or Folio Number
Recipient Name
Signature(Required)
I understand that:
•This authorization does not guarantee continuing benefits. To get benefits, workers or recipients must
continue to meet legal requirements.
•This authorization is for banking or payment purposes only and has no effect on L&I claims.
•If a payment is made in error, I may need to return it.
•L&I and the bank can cancel this agreement, with notice to me.
•This authorization cancels all prior payment method authorizations for listed claims. This authorization will
remain in effect for those claims until I cancel it in writing.
•If I knowingly give false information on this form, L&I may file civil or criminal charges against me.
I am authorized on behalf of
to make this request.
Legal Group Name
I have attached the Articles of Incorporation, Partnership Agreement or bank resolution.
Authorized Signature (Required)
Date
RESET
