Fillable Printable Form F120-211-000
Fillable Printable Form F120-211-000
Form F120-211-000
F120-211-000 Payment Method Authorization 11-2016 Page1 of 2
PO Box 44834
Olympia WA 98504-4834
Payment Method
Authorization Instructions
What can I use this form for?
Use this form to request a new payment method or to change your current payment method with L&I. Until your
new option takes effect, you will continue to receive your benefits through your current payment method.
What are the payment options available?
1. Direct Deposit
2. US Bank Debit Card
3. Paper Check
Who can complete this form?
The claimant or alternate recipient(s) authorized to receive benefits on an open or pension claim.
If you are an alternate recipient, complete your information in the person receiving payment section of the
application.
If you’re signing this form for a worker or alternate recipient, L&I must have legal documentation on file for the
request to be processed (for example: power of attorney, guardianship paperwork, etc.).
When will my direct deposit start?
It can take up to 30 business days for a direct deposit request to process.
Direct deposit limitations:
L&I can only make direct deposits into banks and credit unions in the United States and US territories.
How does the debit card work?
Once we receive your request, you’ll receive a debit card from US Bank in about 10 business days. Once you
activate your card, your benefit payments are deposited directly onto your debit card.
There are no monthly service charges associated with the debit card. In addition, if you use your debit card at a
US Bank ATM, you will not be charged a transaction fee. However, there may be transaction fee charged to
you if you use your debit card at non-US Bank locations. If you want more information about the debit card,
including limitations and fees, please visit www.ReliaCard.com
.
Paper check:
If you are currently receiving a paper check and want to continue receiving a paper check, you don’t need to
complete this form.
How will I know my Direct Deposit or Debit Card payment method request is accepted?
Your receipt of payment into your bank account or onto your debit card is your notification of payment method
acceptance.
If we are unable to process your form, you will be notified by phone or mail.
How do I update my address?
The address L&I has on file for you must match the information on this form.
You can update your address with L&I through the Claim Account Center online or by completing the Address
Change Request for Injured Workers, Crime Victims Address Change Request or Address Change Request for
Pensioners all of these forms can be found on www.Lni.wa.gov.
Still have questions about how to complete this form?
Call toll free 844-728-5204 or 360-902-4675 or 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.
F120-211-000 Payment Method Authorization 11-2016 Page2 of 2
Return completed forms to:
Department of Labor and Industries
PO Box 44834
Olympia WA 98504-4834
Or fax to: 360-902-4674
Payment Method
Authorization Form
Please read the instruction on the previous page before completing this form. Print clearly using blue or black
ink. Fill out this form completely, sign, and return to the address or fax number listed above.
Claimant information
Claim/Folio/L&I Account Number
Claimant Name
I want to receive a paper check for my payments. Just sign at the bottom. You don’t need to
complete the rest of the form.
Person receiving payment information (All fields are required unless otherwise noted.)
Your Name (Last Name, First Name, Middle Initial)
Your Social Security Number
Mailing Address
City State Zip Code
Your Date of Birth (required for debit cards)
Phone Number including Area Code
Email address (optional)
I want to receive direct deposit for my payments or update my bank information.
(See example for routing and account numbers)
Bank Name
Account Type
Checking Savings
Routing Number
Bank Account Number ― Not your debit card #
I want to receive an L&I debit card for my payments.
US Bank will send your debit card to the mailing address we have on file for you.
I understand that:
• This authorization does not guarantee continuing benefits. To get benefits, I must continue to meet legal
requirements.
• This authorization is for banking or payment purposes only and has no effect on my L&I claim.
• If I am not entitled to a payment, I may need to return it.
• L&I can adjust my account for deposits made in error.
• L&I and the bank can cancel this agreement, with notice to me.
• This authorization cancels all prior payment method authorizations. This authorization will remain in effect
until I cancel it in writing.
• If I have an attorney on file, my attorney must authorize in writing any changes to my payment method.
• If I knowingly give false information on this form, L&I may file civil or criminal charges against me.
Signature (Required)
Date
Routing Number
(Nine Digits)
Account Number
can vary in length
RESET
