Form Dd2 - Direct Deposit Application printable pdf download

Optional Form

Public Partnerships, LLC

FORM - DD2

Revised 5/2012

DIRECT DEPOSIT APPLICATION

CREATE/CHANGE PPL Direct Deposit Account or CLOSE Existing PPL Direct Deposit Account

Check the appropriate box below based on your request.

New Direct Deposit Set-up

Change Account Number

Cancellation Request

New Pay Card/Debit Card Set-up

Change Account Type

Change Financial Institution

PAYEE INFORMATION

Disclosure of your Social Security Number (SSN) is voluntary pursuant to 42 USC 405c2C. PPL will use to file required information returns to IRS.

1. Social Security Number (SSN)

2. Payee Name

3. Phone

4. Payee Address

5. City

6. State

7. Zip

AUTHORIZATION FOR SET-UP, CHANGE OR CANCELLATION

I authorize Public Partnerships, LLC (PPL) to process payments owed to me for services authorized by the West Virginia Personal Options self-directed program. Per my request,

PPL will deposit my payment directly to my bank or pay card account indicated below using an Automated Clearing House (ACH) transaction. I recognize that if I fail to provide

complete and accurate information on this form, processing may be delayed or made impossible, or my electronic payments may be erroneously made.

I authorize PPL to withdraw from the designated account all amounts deposited electronically in error. If the designated account is closed or has an insufficient balance to allow

withdrawal, then I authorize PPL to withhold any payment owed to me by PPL until the erroneous deposited amounts are repaid. If I decide to change or revoke this authorization,

I recognize that I must forward such notice to PPL. The change or revocation is effective on the day PPL processes the request.

I certify that I have read and agree to comply with PPL rules governing payments and electronic transfers as they exist on the day of my signature on this form or as subsequently

adopted, amended, or repealed.

I authorize PPL to stop making electronic transfers to my account without advance notice.

If I choose to have my payments deposited to a pay card or debit card, I accept all responsibility for all terms, conditions and/or fees that may be applicable to my chosen pay

card/debit card.

I certify that I am authorized to contract for the entity receiving deposits per this agreement, and that all information provided is accurate.

8. Signature (Required)

9. Title

10. Date

ACCOUNT DETAIL INFORMATION

11. Financial Institution Name (My Bank or my Pay Card Bank's Name)

12. Bank Address

14. Account Type:

13. Bank Routing Number

Checking

Savings