"Electronic Funds Transfer Authorization Form" - Georgia (United States)

Electronic Funds Transfer Authorization Form is a legal document that was released by the Georgia Department of Banking and Finance - a government authority operating within Georgia (United States).

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Download "Electronic Funds Transfer Authorization Form" - Georgia (United States)

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Department of Banking and Finance
2990 Brandywine Road, Suite 200
Atlanta, Georgia 30341-5565
Nathan Deal
770-986-1633
Kevin B. Hagler
Governor
http://dbf.georgia.gov
Commissioner
M E M O R A N D U M
TO: President/CEO of State-Chartered Banks and Credit Unions
RE: Annual Assessments for State-Chartered Financial Institutions
Section 7-1-41 of the Official Code of Georgia and Chapter 80-5-1 of the Rules of the Department of
Banking and Finance govern the assessment of annual examination and supervision fees for state-
chartered banks and credit unions. Annual assessments are for the Department’s fiscal year, July 1
through June 30, and are payable on or before September 15 of each year.
The Department uses a system for payment that allows assessments which are payable to the
Department to be transferred electronically from the bank or credit union account directly into the
Department’s bank account. This system of collection is mandatory and eliminates the necessity of
writing and mailing checks. It is a safe, efficient means of making payments which has been used in
the business community for many years. Payments move almost instantaneously from the bank or
credit union account to the Department’s account, ensuring that your payment is received no later than
the due date. This electronic method of funds transfer will be in the form of an automated clearing
house (“ACH”) debit.
Please complete the attached Electronic Funds Transfer Authorization Form and return it to the
Department as soon as possible. Information on the following pages is designed to help answer
questions which you may have about our system of collection. The Department of Banking and
Finance’s goal is to make this a simple process that will benefit both you and the State of Georgia.
You will receive a Statement on or about August 15 of each year which will reflect the institution’s
pro rata assessment of the State of Georgia’s fiscal year appropriation for the Department of Banking
and Finance. The assessment will be based on the institution’s most recent June 30 Call Report of
Condition. On September 15 of each year, or the next business day if such date is a weekend or
holiday, the Department will initiate the ACH debit which will transfer funds from the institution’s
account into the Department’s account. Please contact either Chris Pittman at 770-986-1641 or
Charlene Haynie at 770-986-5038 if you have any questions after reading the attached information.
Sincerely,
Renee` Martin
Renee` Martin, CPA
Deputy Commissioner for Administration
Department of Banking and Finance
2990 Brandywine Road, Suite 200
Atlanta, Georgia 30341-5565
Nathan Deal
770-986-1633
Kevin B. Hagler
Governor
http://dbf.georgia.gov
Commissioner
M E M O R A N D U M
TO: President/CEO of State-Chartered Banks and Credit Unions
RE: Annual Assessments for State-Chartered Financial Institutions
Section 7-1-41 of the Official Code of Georgia and Chapter 80-5-1 of the Rules of the Department of
Banking and Finance govern the assessment of annual examination and supervision fees for state-
chartered banks and credit unions. Annual assessments are for the Department’s fiscal year, July 1
through June 30, and are payable on or before September 15 of each year.
The Department uses a system for payment that allows assessments which are payable to the
Department to be transferred electronically from the bank or credit union account directly into the
Department’s bank account. This system of collection is mandatory and eliminates the necessity of
writing and mailing checks. It is a safe, efficient means of making payments which has been used in
the business community for many years. Payments move almost instantaneously from the bank or
credit union account to the Department’s account, ensuring that your payment is received no later than
the due date. This electronic method of funds transfer will be in the form of an automated clearing
house (“ACH”) debit.
Please complete the attached Electronic Funds Transfer Authorization Form and return it to the
Department as soon as possible. Information on the following pages is designed to help answer
questions which you may have about our system of collection. The Department of Banking and
Finance’s goal is to make this a simple process that will benefit both you and the State of Georgia.
You will receive a Statement on or about August 15 of each year which will reflect the institution’s
pro rata assessment of the State of Georgia’s fiscal year appropriation for the Department of Banking
and Finance. The assessment will be based on the institution’s most recent June 30 Call Report of
Condition. On September 15 of each year, or the next business day if such date is a weekend or
holiday, the Department will initiate the ACH debit which will transfer funds from the institution’s
account into the Department’s account. Please contact either Chris Pittman at 770-986-1641 or
Charlene Haynie at 770-986-5038 if you have any questions after reading the attached information.
Sincerely,
Renee` Martin
Renee` Martin, CPA
Deputy Commissioner for Administration
Department of Banking and Finance
Electronic Funds Transfer Authorization Form
1. Name of Bank or Credit Union: _____________________________________________
FDIC CERT# (Banks):__________ or NCUA Charter# (Credit Unions): ___________
2. Address: _______________________________________________________________
City/State/ZIP: __________________________________________________________
st
3. 1
Contact Person: _______________________ Title: ________________________
Phone: ________________________ Ext: _________ Fax: _________________
E-mail Address: ____________________________________________________
nd
4. 2
Contact Person: _______________________ Title: ________________________
Phone: ________________________ Ext: _________ Fax: ________________
E-mail Address: ____________________________________________________
5. Type of Electronic Funds Transfer: ACH-DEBIT
Bank: ____________________________________________________________
Mailing Address: ___________________________________________________
City/State/ZIP: _____________________________________________________
Transit/Routing #: __________________________________________________
Bank Account #: ______________________ [ ] Checking [ ] Savings (check one)
6. Bank Contact Person: ______________________________________________________
Title: ____________________ Phone: ______________Email: ________________
7.
I/we authorize the Georgia Department of Banking and Finance to present debit entries into the
bank account referenced above. The debits will represent amounts owed to the Department of
Banking and Finance in accordance with the provisions of Section 7-1-41 of the Official Code of
Georgia and Chapter 80-5-1 of the Rules of the Department.
Signature: ____________________________Title: __________________ Date: __________
Signature: ____________________________Title: __________________ Date: __________
Please complete and return by Email (accounting@dbf.state.ga.us) or fax (770) 986-1274
Department of Banking and Finance
Instructions for Completing the Electronic Funds
Transfer Authorization Form
The name of the financial institution making payment.
1. Name of Bank or Credit Union:
FDIC CERT# or NCUA Charter#:
State-chartered banks should enter their FDIC Certificate
Number (CERT).
State-chartered credit unions should enter their NCUA
Charter Number.
2. Address:
The address to which all correspondence regarding EFT/ACH
Debit should be mailed.
st
3. 1
Contact Person:
The primary person who should be contacted in the event of a
problem or error with an electronic funds transfer and to
whom all correspondence regarding EFT payment should be
mailed.
nd
4. 2
Contact Person:
Additional contact person.
5. Type of EFT: (ACH Debit):
This is the pre-authorized withdrawal of funds from the
institution’s designated bank account.
Bank Name, Mailing Address, and City/State/Zip of the bank
from which funds should be withdrawn.
The 9 digit Transit/Routing Number of the bank from which
funds should be withdrawn.
The Bank Account Number from which funds should be
written.
6. Bank Contact Person:
Bank contact person for ACH Debit Accounts.
7. Signature, title of person authorizing the transfer of monies through the ACH System and date. (The
person with the authority to sign checks on your account should be the one/ones signing the Electronic
Funds Transfer Authorization Form.)
Department of Banking and Finance
Information sheet about Electronic Funds Transfer
Funds Transfer Date
Your funds will be transferred on September 15 of each year.
How will the Electronic Funds Transfer system work?
The ACH Debit method will be utilized. ACH is the abbreviation for Automated Clearing House.
The ACH is a central distribution and settlement point, usually the Federal Reserve Bank for the
electronic clearing of debits and credits between financial institutions.
Every day millions of
transactions occur all over the nation, with funds being deleted from, or added to, the balances of
participating financial institutions, which in turn reflect those transactions in their internal accounting
for individual bank customers. Because it is the least expensive and most efficient method of moving
money, it is becoming more widely used than any other transfer system.
What do I do when using the ACH Debit?
The bank or credit union will receive a Statement on or about August 15 of each year. The Statement
will reflect each financial institution’s pro rata assessment of the State of Georgia’s fiscal year
appropriation for the Department of Banking and Finance. The assessment will be based on the
institution’s most recent June 30 Call Report of Condition. On September 15 of each year, or the next
business day if such date is a weekend or holiday, the Department of Banking and Finance will initiate
the ACH Debit, which will electronically transfer funds from the institution’s account into the
Department’s account. No action will be required of the bank or credit union.
Costs?
There is no cost or charge to the financial institution when an ACH Debit is used to pay the annual
assessment.
What about late payments?
Penalties may be assessed if circumstances within your control cause a late payment.
Who do I call with EFT questions?
You may call Chris Pittman at 770-986-1641 or Charlene Haynie at 770-986-5038.
Will the banking information I provide the Department of Banking and Finance be confidential
and secure?
The use of EFT payment system provides a safe, secure, proven, and efficient method of moving
money from one account into another.
All information provided to the Department is strictly
confidential.
How do I make changes to bank information or other information on the Electronic Funds
Transfer Authorization Form?
If you change banks, account number, or location you must notify the Department in writing by July
31 and complete a new Electronic Funds Transfer Authorization Form.
What should I do if a “0” amount is due?
No action is required.
Can I continue to make payments as usual if I prefer not to use the ACH Debit Method?
No. Use of the ACH debit method for payments of assessments is mandatory.
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