Fillable Form 4200-F-05 Bank Draft Authorization printable pdf download

Form 4200-F-05 Bank Draft Authorization

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STATE OF ARKANSAS

EMPLOYEE BENEFITS DIVISION

501 Woodlane, Suite 500

Department of Finance

Little Rock, AR 72201-1011

Post Office Box 15610

and Administration

Little Rock, AR 72231-5610

Phone: (501) 682-9656

Toll Free: (877) 815-1017

BANK DRAFT AUTHORIZATION

I (we) hereby authorize the Department of Finance and Administration – Employee Benefits Division to initiate debit entries

and to initiate, if necessary, credit entries and adjustments for any debits in error to our bank account indicated at the

financial institution named below (VOIDED CHECK), hereinafter called Depository, to debit and/or credit the same such

account.

Retirement

COBRA

Effective Date: ________________

Type of Account

Date of Draft

COBRA – all COBRA NSF drafts must

be paid by end of month to avoid termination

of COBRA health insurance.

Checking

(Require Voided Check)

Savings**

(Retirement Only)

**Routing #:_________________________

Deduction Amount: $_____________

**Account #:_________________________

Update to current account

This authorization shall remain in effect unless the Employee Benefits Division has received written notification from me

(us) of its termination in such time and in such manner as to afford the Employee Benefits Division and Depository a

reasonable opportunity to act on it.

Authorized Signer on Account: ____________________________________________________

(Please print name clearly)

: ______________________________________________

Insured’s Social Security No

(Authorized Signer)

(Date)

_____________________________________________________________________________________________

Per Arkansas Code S5-37-301, a $25.00 Return Item Charge fee plus a $2.00 service fee for bank drafts will be

assessed per item returned not paid by the bank.

Enclose a Voided Check for Checking Accounts – must have original check – no copies

(Deposit Slip Cannot Be Used)

Return this authorization to:

Employee Benefits Division

Entered: __________

PO Box 15610

Date

Little Rock, AR 72231-5610

Initialed: __________

Rev. 06/10/14

4200-f-05

Form 4200-F-05 Bank Draft Authorization

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