Direct Deposit Authorization Form - Iowa Department Of Administrative Services

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Direct Deposit Authorization Form

SECTION 1 – TRANSACTION TYPE

ARE YOU ADDING, CHANGING OR CANCELING THIS AGREEMENT?

ADD

CHANGE

CANCEL

The agreement represented by this authorization remains in effect until canceled by the payee and until such time, payments made by the State of Iowa to you will be

deposited into the account at the financial institution designated below. You will be required to submit a new form for any change in banking designation or to cancel this

authorization and revert to a state warrant. It is your responsibility to notify the State of Iowa any time an account is closed.

An add or change in EFT status will be effective ten business days after entry into the State's accounting system. A cancelation will become effective immediately after entry

into the State's accounting system.

SECTION 2 – BUSINESS / INDIVIDUAL IDENTIFICATION INFORMATION

BUSINESS/INDIVIDUAL LEGAL NAME:

(NAME TAX ID IS ASSIGNED TO AND USED FOR TAX REPORTING)

BUSINESS NAME:

(DBA – DOING BUSINESS AS NAME) IF DIFFERENT FROM LEGAL NAME

SSN

or FEIN (Fed. Employee ID Number)

MAILING ADDRESS:

(ADDRESS TO BE USED IN CASE OF DEFAULT TO CHECK)

CITY:

STATE:

ZIP:

SECTION 3 – FINANCIAL INSTITUTION – TO BE COMPLETED BY FINANCIAL INSTITUTION

(NOT REQUIRED IF FOR CHECKING ACCOUNT ONLY AND A COPY OF VOIDED CHECK IS ATTACHED – DO NOT ATTACH DEPOSIT SLIP)

FINANCIAL INSTITUTION NAME:

FINANCIAL INSTITUTION ADDRESS:

CITY:

STATE:

ZIP:

NAME ON ACCOUNT:

ROUTING TRANSIT NUMBER:

ACCOUNT TYPE:

SAVINGS

CUSTOMER ACCOUNT NUMBER:

CHECKING

I have verified the signature(s) and account numbers above. The Financial Institution is ACH capable and will comply with NACHA rules.

REPRESENATATIVE NAME:

REPRESENTATIVE TITLE:

SIGNATURE:

DATE:

TELEPHONE NUMBER:

SECTION 4 – VENDOR AUTHORIZATION FOR ADD, CHANGE OR CANCELLATION

I hereby authorize the Department of Administrative Services to deposit payments from the State of Iowa to the account designated on this form and to initiate any

adjustments or debit entries to this account for any erroneous deposits in the amount of the error only. I also understand that the State of Iowa can only deposit funds into one

financial institution and account.

I certify that I am authorized to enter into this agreement as the account holder or on behalf of the account holder.

AUTHORIZED NAME:

TITLE:

DATE:

AUTHORIZED SIGNATURE:

TELEPHONE NUMBER:

Mail or Fax Completed Form to:

Fax Number:

Telephone Number:

Dept. of Administrative Services – State Accounting Enterprise

(515) 281-5255