Direct Deposit Form (Page 2 of 2) in pdf

DIRECT DEPOSIT INSTRUCTIONS

The authorization form below gives MLFCCA and your financial institution authority to deposit

your CACFP reimbursement into your checking or savings account each month. Please

complete and return this entire form to the MLFCCA office.

All you need to do is:

Mark the box for checking or savings to indicate whether your CACFP reimbursement

will be deposited into your checking or savings account.

Fill in your name, financial institution name and location, and the date.

To deposit into a checking account: Attach a voided check for verification of all

financial institution information. Use a blank check and write VOID across it.

To deposit into a savings account: Enclose a savings account deposit slip.

PROVIDER'S AUTHORIZATION

Each month, I authorize MLFCCA and the financial institution listed below to initiate electronic

credit entries and if necessary, debit entries and adjustments for any credit entries in error to

my:

_____ Checking Account (attach a voided check) OR

_____ Savings Account (attach a savings deposit slip)

This authority will remain in effect until I have cancelled it by phone, e-mail, or in writing.

Date: _______________

Name (Please Print): __________________________________________________________

Telephone Number: (______)_______________________ Provider ID #: ________________

Financial Institution: ___________________________________________________________

Branch: __________________________________ City ___________________ State_______

Account # at Financial Institution: ________________________________________________

Transit Routing Number: _______________________________________________________

Signature___________________________________________________________________

Direct Deposit Form Page 2