Form 117H2 "Authorization for Electronic Deposit" - Oregon

What Is Form 117H2?

This is a legal form that was released by the Oregon Department of Revenue - a government authority operating within Oregon. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on May 1, 2016;
  • The latest edition provided by the Oregon Department of Revenue;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a fillable version of Form 117H2 by clicking the link below or browse more documents and templates provided by the Oregon Department of Revenue.

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Download Form 117H2 "Authorization for Electronic Deposit" - Oregon

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Authorization for Electronic Deposit
Instructions:
Please print your name, Social Security Number, and financial institution on the top lines. Fill in your
financial institution’s branch address, city, state, zip code, and the telephone number of the branch you
use. Check the box that tells us what to do (start or terminate electronic deposit). Mark the box to tell
us into which account (checking or savings), you want your benefit payment deposited.
If you want your benefits deposited in your checking account, include a voided check (write “VOID”
across the check). Fill in your account and bank routing numbers. If you want your benefits deposited in
your savings account, include a voided deposit slip (write “VOID” across the deposit slip).
Sign and date the completed form. If mailing, put the completed form (along with your voided check or
deposit slip) into an envelope with first class postage.
Oregon Employment Department
Electronic Deposit Unit-Rm 105
Please mail or fax this form with a voided check or deposit slip to:
875 Union St. NE
*Please note that signing this form electronically has the same
Salem, Or 97311
meaning and validity as your handwritten signature.
Fax: (503) 947-1335
-------------------------------------------------------------------------------
Authorization for Electronic Deposit
Start
Terminate
Name: (Please Print)
Social Security Number:
BYE:
Financial Institution:
Branch Phone:
Address of Your Branch:
City, State, Zip Code:
I authorize the State of Oregon Employment Department to electronically deposit weekly payment in the
above named financial institution. I authorize the above named institution to accept and distribute said funds
in the matter designated by me.
Checking
Bank Routing Number:
Savings
Account Number:
I understand that this authorization will override any previous authorization, and will remain in effect until the
Employment Department receives written notice of its termination, or one year has passed since I last claimed.
Signature
Today’s Date
Form 117H
2
Oregon Employment Department |
www.Employment.Oregon.gov
(Revised 0516)
Authorization for Electronic Deposit
Instructions:
Please print your name, Social Security Number, and financial institution on the top lines. Fill in your
financial institution’s branch address, city, state, zip code, and the telephone number of the branch you
use. Check the box that tells us what to do (start or terminate electronic deposit). Mark the box to tell
us into which account (checking or savings), you want your benefit payment deposited.
If you want your benefits deposited in your checking account, include a voided check (write “VOID”
across the check). Fill in your account and bank routing numbers. If you want your benefits deposited in
your savings account, include a voided deposit slip (write “VOID” across the deposit slip).
Sign and date the completed form. If mailing, put the completed form (along with your voided check or
deposit slip) into an envelope with first class postage.
Oregon Employment Department
Electronic Deposit Unit-Rm 105
Please mail or fax this form with a voided check or deposit slip to:
875 Union St. NE
*Please note that signing this form electronically has the same
Salem, Or 97311
meaning and validity as your handwritten signature.
Fax: (503) 947-1335
-------------------------------------------------------------------------------
Authorization for Electronic Deposit
Start
Terminate
Name: (Please Print)
Social Security Number:
BYE:
Financial Institution:
Branch Phone:
Address of Your Branch:
City, State, Zip Code:
I authorize the State of Oregon Employment Department to electronically deposit weekly payment in the
above named financial institution. I authorize the above named institution to accept and distribute said funds
in the matter designated by me.
Checking
Bank Routing Number:
Savings
Account Number:
I understand that this authorization will override any previous authorization, and will remain in effect until the
Employment Department receives written notice of its termination, or one year has passed since I last claimed.
Signature
Today’s Date
Form 117H
2
Oregon Employment Department |
www.Employment.Oregon.gov
(Revised 0516)