"Direct Deposit Authorization Form" - Iowa

Direct Deposit Authorization Form is a legal document that was released by the Iowa Department of Administrative Services - a government authority operating within Iowa.

Form Details:

  • Released on July 1, 2014;
  • The latest edition currently provided by the Iowa Department of Administrative Services;
  • Ready to use and print;
  • Easy to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a fillable version of the form by clicking the link below or browse more documents and templates provided by the Iowa Department of Administrative Services.

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Direct Deposit Authorization Form
SECTION 1 – TRANSACTION TYPE
A
A
, C
C
A
?
RE YOU
DDING
HANGING OR
ANCELING THIS
GREEMENT
ADD
CHANGE
CANCEL
1) 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.
2) You are required to submit a new form for any change in banking designation or to cancel this authorization and revert to a state warrant.
3) It is your responsibility to notify the State of Iowa any time an account is closed.
4) An add or change in EFT status will be effective ten business days after entry into the State's accounting system.
5) A cancelation will become effective immediately after entry into the State's accounting system.
SECTION 2 – BUSINESS / INDIVIDUAL IDENTIFICATION INFORMATION
B
I
L
N
/
USINESS
NDIVIDUAL
EGAL
AME
Name Tax ID is Assigned To and Used for Tax Reporting
B
N
USINESS
AME
DBA (Doing Business As) If Different than Legal Name
SSN
FEIN
OR
Social Security Number
Federal Employee ID Number
M
A
AILING
DDRESS
Address to be used in case of Default to Check
C
S
Z
ITY
TATE
IP
SECTION 3 – BANKING INFORMATION
1) A voided check or copy of enrollment confirmation if a pre-paid card, or
2) The financial institution must complete the representative box within Section 3, or
Section 3 requires one of three items:
3) The financial institution must supply a bank account verification letter.
F
I
N
INANCIAL
NSTITUTION
AME
F
I
A
INANCIAL
NSTITUTION
DDRESS
C
S
Z
ITY
TATE
IP
A
T
:
N
A
CCOUNT
YPE
AME ON
CCOUNT
R
T
N
OUTING
RANSIT
UMBER
S
AVINGS
C
A
N
USTOMER
CCOUNT
UMBER
C
HECKING
REQUIRED
IF REQUESTING A CHANGE:
OLD Routing Number:
OLD Account Number
I have verified the signature(s) and account numbers above. The Financial Institution is ACH capable and will comply with NACHA rules.
R
N
R
T
EPRESENTATIVE
AME
EPRESENTATIVE
ITLE
S
IGNATURE
D
P
N
ATE
HONE
UMBER
SECTION 4 –
REQUIRED
VENDOR AUTHORIZATION FOR ADD, CHANGE OR CANCELATION
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.
A
N
T
D
UTHORIZED
AME
ITLE
ATE
S
P
N
IGNATURE
HONE
UMBER
Dept. Admin Services-State Accounting Enterprise
Mail or Fax Completed Form to:
Attn: EFT Coordinator
rd
Hoover State Office Building, 3
FL
Fax Number
Phone Number
(515) 281-5255
Des Moines, Iowa 50319
(515) 281-0246
Updated 07/2014
Direct Deposit Authorization Form
SECTION 1 – TRANSACTION TYPE
A
A
, C
C
A
?
RE YOU
DDING
HANGING OR
ANCELING THIS
GREEMENT
ADD
CHANGE
CANCEL
1) 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.
2) You are required to submit a new form for any change in banking designation or to cancel this authorization and revert to a state warrant.
3) It is your responsibility to notify the State of Iowa any time an account is closed.
4) An add or change in EFT status will be effective ten business days after entry into the State's accounting system.
5) A cancelation will become effective immediately after entry into the State's accounting system.
SECTION 2 – BUSINESS / INDIVIDUAL IDENTIFICATION INFORMATION
B
I
L
N
/
USINESS
NDIVIDUAL
EGAL
AME
Name Tax ID is Assigned To and Used for Tax Reporting
B
N
USINESS
AME
DBA (Doing Business As) If Different than Legal Name
SSN
FEIN
OR
Social Security Number
Federal Employee ID Number
M
A
AILING
DDRESS
Address to be used in case of Default to Check
C
S
Z
ITY
TATE
IP
SECTION 3 – BANKING INFORMATION
1) A voided check or copy of enrollment confirmation if a pre-paid card, or
2) The financial institution must complete the representative box within Section 3, or
Section 3 requires one of three items:
3) The financial institution must supply a bank account verification letter.
F
I
N
INANCIAL
NSTITUTION
AME
F
I
A
INANCIAL
NSTITUTION
DDRESS
C
S
Z
ITY
TATE
IP
A
T
:
N
A
CCOUNT
YPE
AME ON
CCOUNT
R
T
N
OUTING
RANSIT
UMBER
S
AVINGS
C
A
N
USTOMER
CCOUNT
UMBER
C
HECKING
REQUIRED
IF REQUESTING A CHANGE:
OLD Routing Number:
OLD Account Number
I have verified the signature(s) and account numbers above. The Financial Institution is ACH capable and will comply with NACHA rules.
R
N
R
T
EPRESENTATIVE
AME
EPRESENTATIVE
ITLE
S
IGNATURE
D
P
N
ATE
HONE
UMBER
SECTION 4 –
REQUIRED
VENDOR AUTHORIZATION FOR ADD, CHANGE OR CANCELATION
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.
A
N
T
D
UTHORIZED
AME
ITLE
ATE
S
P
N
IGNATURE
HONE
UMBER
Dept. Admin Services-State Accounting Enterprise
Mail or Fax Completed Form to:
Attn: EFT Coordinator
rd
Hoover State Office Building, 3
FL
Fax Number
Phone Number
(515) 281-5255
Des Moines, Iowa 50319
(515) 281-0246
Updated 07/2014