Direct Deposit Authorization Agreement Form - Housing Authority Of The City & County Of Denver Page 2
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2DHA Use Only:
Housing Authority of the City & County of Denver
Entity # ________________
Housing Choice Voucher Program
Date Entered: ___________
DIRECT DEPOSIT AUTHORIZATION AGREEMENT
HOW TO COMPLETE THIS FORM
1. Read the reverse of this form completely, making
voided check. See example below.
sure you understand the terms and conditions of
4. If the account is not in your name alone, have the
the agreement.
other account holder sign also.
2. Fill in all boxes below.
5. Mail the form to: Denver Housing Authority – Section 8,
3. Sign and date the form & attach preprinted
PO box 40305, Denver, CO 80204-0305
Business Name
Last Name
First Name
MI
Tax Identification Number/Social Security number (Last Four Digits Only)
Phone
Action
Effective Date
New
Change Cancel
Month
Day
Year
Name of Financial Institution
Account Number
(Include hyphens, but omit spaces and special symbols)
Type of Account
Checking Savings
Routing Transit Number
Ownership of Account
(all 9 boxes must be filled. The first two numbers
must be 01 through 12 or 21 through 32)
Self
Joint
Other
I certify that I have read and understand the back of this form. By signing this agreement, I authorize the Housing Authority of the City
and County of Denver (DHA) to initiate credit to the account indicated above for the purpose of payment of Housing Assistance
Payment (HAP) obligations. I also authorize DHA to initiate, if necessary, debit entries and adjustments to any HAP contract(s) for HAP
overpayments or HAP errors.
Signature __________________________________________________________________________Date ____________________
If the account is a joint account or in someone else’s name, that individual must also agree to the terms stated above by signing below.
Signature __________________________________________________________________________Date ____________________
JOHN or MARY PUBLIC
1234
Call your financial institution to
TIP
make sure they will accept direct
123 Main Street
___________________20____
deposit
Your Town, CO 12345
Verify your account number and
PAY TO THE
TIP
routing transit number with your
$
ORDER OF________________________________________________________________
financial institution
Your Town Bank _________________________________________________________DOLLARS
Do not use a deposit slip to verify
Your Town, CO 12345
TIP
the routing number
For ________________________________
______________________________________________
Routing Transit Number
l: 250000005
i:234556789022 ll‘
Account
Number
NOTE: THE ACCOUNT AND ROUTING NUMBER MAY APPEAR IN DIFFERENT PLACES ON YOUR CHECK
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