Authorization Agreement For Electronic Funds Transfer Form

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AUTHORIZATION AGREEMENT FOR ELECTRONIC FUNDS TRANSFER (SCO EFT-1)
Complete Section I Below:
Branch #
000000
New EFT Account
Change EFT Remittance Method
Please Check Appropriate Boxes
Change Bank Account
Change in Holder Contact Information
HOLDER INFORMATION
__ __ - __ __ __ __ __ __ __
FEDERAL EMPLOYER ID# (FEIN):
NAME
ADDRESS
CITY
STATE
ZIP
( _ _ _ ) _ _ _ - _ _ _ _
__ __
UNCLAIMED PROPERTY HOLDER TYPE CODE
PHONE
EXT
CONTACT INFORMATION - REPORT FILER
NAME
EMAIL
( _ _ _ ) _ _ _ - _ _ _ _
( _ _ _ ) _ _ _ - _ _ _ _
PHONE
EXT
FAX
Complete Section II, III or IV Below:
If you have selected the ACH Debit option, you MUST either attach a voided check OR a letter,
SECTION II
ACH DEBIT
on company letterhead, noting your Bank Transit Routing Number and Bank Account Number.
This information will be used only to verify bank account, transit and routing numbers.
BANK NAME:
__ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __
BANK ACCOUNT NUMBER (not to exceed 17 digits):
__ __ __ __ __ __ __ __ __
TRANSIT AND ROUTING NUMBER: (not to exceed 9 digits):
CHECKING
SAVINGS
TYPE OF ACCOUNT:
Method of Communication: (Check One)
Phone (Voice)
Phone (Touch Tone)
Web Payor
SIGNATURE
TITLE
DATE
SECTION III
ACH CREDIT
I have verified our company’s Financial Institution can originate an ACH Credit transaction in the required record field.
SIGNATURE:
TITLE
DATE
SECTION IV
INTERNATIONAL FUNDS TRANSFER
SIGNATURE
TITLE
DATE
For EFT assistance Call (916) 464-6220 or EMAIL
updscoeft@sco.ca.gov
You may fax the completed EFT-1 Form to (916) 464-622
4
or mail a copy to
State Controller's Office, Unclaimed Property Division, Attention: EFT Unit
P.O. Box 942850, Sacramento, CA 94250-5873
Rev. 01/2011
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