Form Ldol 971w - Agreement For Direct Deposit
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1AGREEMENT FOR DIRECT DEPOSIT
Name (Please Print)
Social Security No.
START
I authorize the Louisiana Department of Labor, Office of Regulatory Services, to make automatic
deposit of the full amount of any payments of my weekly unemployment benefits to my:
CHECKING ACCOUNT
SAVINGS ACCOUNT
STOP
I authorize the Louisiana Department of Labor, Office of Regulatory Services, to terminate the
automatic deposit of any payments of my unemployment benefits.
CHANGE
I authorize the Louisiana Department of Labor, Office of Regulatory Services, to change the
automatic deposit of any payments of my unemployment benefits according to the changes listed
below.
I understand that the Louisiana Department of Labor, Office of Regulatory Services, can automatically deposit unemployment
benefits only to a separate or joint banking account under which the name of the above claimant is listed.
I UNDERSTAND THAT IT IS MY OWN RESPONSIBILITY TO VERIFY ANY SUCH DEPOSITS OF
UNEMPLOYMENT BENEFITS WITH MY BANKING INSTITUTION.
NAME OF BANK OR FINANCIAL INSTITUTION
CITY
STATE
ZIP
BANK ACCOUNT NUMBER
TYPE OF ACCOUNT
Checking
Savings
TRANSIT AND
ROUTING NO.
This authorization shall remain in effect until the Louisiana Department of Labor has received written notification from me to
terminate or otherwise change the automatic deposit of my unemployment benefits. Such notification shall be delivered in a
timely manner in order to afford the Louisiana Department of Labor an opportunity to comply. In no event shall any such
termination or change affect any unemployment benefits previously processed or being processed by the Louisiana Department
of Labor for automatic deposit at the time of receipt of my notification.
In the event of an error in the automatic deposit of my unemployment benefits to my account, I authorize my named banking
institution to correct the error in my account. I understand that if an error is made, I shall receive written notification from the
Louisiana Department of Labor with explanation of such error. I also understand that all transactions with my account by the
Louisiana Department of Labor shall be governed by the Rules of the Louisiana, Alabama, Mississippi Automated Clearing
House Association.
I also understand that the Louisiana Department of Labor is NOT responsible for errors in the bank transit routing numbers or in
the account numbers, as listed above, and is further not responsible in the event that the above selected institution is not
participating in the Direct Deposit program through the Federal Reserve System.
SIGNATURE
DATE
Mail Application To:
FOR OFFICIAL USE ONLY
Louisiana Department of Labor
EFT Processing – U. I. Accounting
CLAIM BYE
P. O. Box 94100
Baton Rouge, LA 70804-9100
____/___/___
LDOL 971W
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Parent category: Legal