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Authority To Make Direct Payments (Ach Debits) - Liquor Division - State Of Wyoming - Department Of Revenue Form

AUTHORITY TO MAKE DIRECT PAYMENTS (ACH DEBITS)

STATE OF WYOMING, DEPARTMENT OF REVENUE

LIQUOR DIVISION

Licensee Information

WLD Customer Number:

Licensee Name:

DBA:

Location Address:

City:

Zip:

Telephone:

Fax:

Email:

Financial Institution Information

Financial Institution Name:

Street Address:

City:

State:

Zip:

Bank Phone Number:

Routing Number:

Account Number:

Account Type:

(only select one)

Checking: ☐

Savings:

☐

Bank Representative Name:

Bank Representative Signature:

Date:

ATTACH CANCELLED OR VOIDED SAMPLE OF CHECK

OBTAIN BANK REPRESENTATIVE SIGNATURE IF

CHECKLESS ACCOUNT

I (we) hereby authorize Wyoming Department of Revenue Liquor Division (WLD), to initiate debit

entries to my (our) account number as indicated above.

This authorization is to remain in full force and effect until WLD has received written notification

from the liquor licensee of its termination in such time and in such manner as to afford WLD a

reasonable opportunity to act on it.

Authorized Signature:

Print Name:

Date:

Please Fax to 307-777-6255

Wyoming Liquor Division • State of Wyoming, Cheyenne WY 82002-0110 • PH (307) 777-7231 • FAX (307) 777-6255

Authority To Make Direct Payments (Ach Debits) - Liquor Division - State Of Wyoming - Department Of Revenue Form