Change Of Bank Information Form - Rhode Island Department Of Health (Page 2 of 2) in pdf

Rhode Island Department of Health

WIC Program

Automated Clearinqhouse ACH I Authodzation Aqreement

FOR REIMBURSEMENT CREDITS or PAYMENT ADJUSTMENTS AT PEER GROUP MAXIMUM PRICE (ACH CREDITS)

AND PENALTY OR FEE COLLECTION (ACH DEBITS)

This form should be completed (for each store) by either the store owner, partner or the WIC registered authority only

Business Name:

Today’s Date:

Pharmacy Name:

Specify, if a different bank accounts:

Name on Store Signs (dba):

Store Phone No:

Store Address:

Zip Code:

City:

Bank report should be mailed to this address:

City:

State:

Zip Code:

Full Legal Owner’s (Person's) Name(s):

(print)

Full Legal Account Holder’s (Person's) Name(s):

Title:

(print)

Full Legal Account Holder’s (Person's) Signature:

(Original Authorized Legal Signature(s))

I (we) hereby authorize and request the RHODE ISLAND DEPARTMENT OF HEALTH - WIC PROGRAM, hereinafter called HEALTH, to initiate

and effect Reimbursement or Payment Credit and/or Penalty or Fee Collection entries of any amounts owing by HEALTH to me (us) and any

amounts owing by me (us) to HEALTH as such amounts become due by initiating Reimbursement or Payment Credit and/or Penalty or Fee

Collection (and the ability to perform a reversal of an erroneous transaction) entries related to WIC transactions to my (our) checking and/or

savings account indicated in the bank name(s) below, hereinafter called BANK and I (we) authorize and request the BANK to direct/accept the

entries related to WIC transactions initiated by HEALTH to such account(s) without responsibility for the correctness thereof. Reimbursement

or Payment Credit will be initiated if a WIC check is submitted for payment above the current maximum price for my peer group. I agree to

accept an adjusted ACH Credit and any related fees if the price on the WIC check(s) submitted for payment exceeds the current maximum price

for my peer group. I (we) (the signor above) certify that I have the legal authority to sign this agreement.

ANY MODIFICATION TO ACCOUNT INFORMATION MUST BE REPORTED IMMEDIATELY

Depository Bank Name:

City:

State:

Zip:

Routing Number

Account Number

Please verify your routing transit and accounts number with your bank or business office before completing this section.

I (we) with the above signature, certify that all the above information is true. I (we) understand that WIC Program officials may verify any

information relating to this certification; and that if I (we) have contributed to any misrepresentation or falsification of information, participation as a

WIC Vendor will be subject to permanent disqualification, denial and/or termination from the WIC Program up to six years, claim for

reimbursement and possible disqualification from the Food Stamp Program and criminal prosecution.

This authorization is to remain in full force and effective until the RHODE ISLAND DEPARTMENT OF HEALTH - WIC PROGRAM has received

written notification from me (us) of its termination

Subscribed and sworn to before me this

day of

SEAL

,20

Original

Commission Expires

Signature:

MUST BE NOTARIZED

As this person a notary you are certifying that this signature is the original and authentic signature of the business owner who is completing this application form.

Notaries are covered under the WIC Law and Regulations associated with any violations that may occur with this application process