Direct Deposit Authorization for Electronic Funds Transfer (EFT)
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1 MN National Guard Circular ANNEX D-1 1 July 2017 Direct Deposit Authorization for Electronic Funds Transfer (EFT) MN Army National Guard 20 12th Street West Saint Paul, MN Attn: Education Services Instructions for completing this form are on the next page. Mailing Address (General) State Benefits Specialist form to: ng.mn.mnarng.mbx.assets-education@mail.mil Please print clearly and use black ink. Name Address City State Zip Code (State Incentives will fill out) Vendor Number Contact Information - Please list person who can respond if additional information is required. Address Phone - - Tax Identification Information Federal ID/Social Security Number Financial Institution Information Note: Do not use /, \, *, - or ~ in any fields in this section. Replace with spaces. ABA Routing Number Customer Account Number Financial Institution Street Address City, State, ZIP Code Type of Account: Checking Savings Authorization to Make Electronic Fund Payments I authorize the Commissioner of Minnesota Management & Budget to deposit, by electronic fund transfer, payments owed to me by the State of Minnesota and, if necessary, debit entries and adjustments for any amounts deposited electronically in error. The Commissioner shall deposit the payments in the financial institution and account designated above. I recognize that if I fail to provide complete and accurate information on this authorization form, the processing of the form may be delayed or my payments may be erroneously transferred electronically. I consent to and agree with the National Automated Clearing House Association Rules and Regulations and the Commissioner's Rule about electronic transfers as they exist on the date of my signature on this form or as subsequently adopted, amended or repealed. Authorized Signature Printed Name Title Date Annex D-1 Direct Deposit & W-9
2 MN National Guard Circular ANNEX D-1 1 July 2017 Notice of Intent to Collect Private Data All payment recipients are asked to provide private data to Minnesota Management & Budget for the following purposes. State employees who support this function of the state s accounting system need to access the data to verify information. Others who have legal access to the data include: Legislative Auditor, Attorney General, enforcement agencies with statutory authority, and any other person or entity authorized by law or court order. Social Security Number (SSN) or Federal Employee Identification Number (FEIN): Needed for identification purposes. This number is used to match recipients with payments. This number is also called a Tax Identification Number or TIN number. You are not legally required to provide this data. However, without this information we cannot convert you to EFT. ABA Routing Number, Account Number, Account Type: This data is required to correctly deposit payments to your designated bank account. You are required by law to provide this information. Incomplete information may cause a delay in converting to EFT. Additionally, incorrect information may cause a payment to be delayed or deposited to the wrong account. Instructions for Completing the Form Determine which bank accounts will be used for direct deposit. A separate copy of the Electronic Fund Transfer Authorization form is required for each bank account. Mailing Address (General) 1. Name, Address, City, State, Zip Code. Enter the name of the business or individual, address, city, state, and zip code. 2. Number. Enter the eleven-digit vendor number, if you know it. If you received this form with a letter, this number is located under the date. If you received this form with a duplicate warrant, the number is located above your name and is listed as Vendor Number and Vendor Location. Contact Information Enter the name, address, phone and FAX number of the person who can respond to questions regarding the information provided on this form. Current Financial Institution Information This information is required to verify that we are changing the correct account. 1. ABA Routing Number. Enter the ABA Routing Number to identify your financial institution. Contact your bank if you are not sure what number to put in this field. 2. Customer Account Number. Enter your bank account number. Contact your bank if you are not sure what number to put in this field. 3. Financial Institution Name. New Account Information 1. ABA Routing Number. Enter the ABA Routing Number to identify your financial institution. Contact your bank if you are not sure what number to put in this field. 2. Customer Account Number. Enter your bank account number. Contact your bank if you are not sure what number to put in this field. 3. Financial Institution Name, Address, City, State, Zip Code. Enter the name and address of your financial institution. 4. Type of Account. Indicate if the account listed on this form is a checking or savings account. Authorization to Make Electronic Fund Payments Sign the form and print your name and title (if any) and the date. Send the Form You can , mail or fax the form to the Department of Military Affairs: ng.mn.mnarng.mbx.assets-education@mail.mil J1 Education and Incentives MN Army National Guard 20 West 12th Street St. Paul, MN Attn: State Benefits Specialist FAX number: (651) Questions about this Form? Call the State Benefits Specialist at (651) ; or, ng.mn.mnarng.mbx.assets-education@mail.mil Tax Identification Information 1. Federal ID/ Social Security Number and Name. Enter the nine-digit Federal Employer Identification Number (FEIN) for business, or the nine-digit Social Security Number (SSN). Enter the name associated with either the FEIN or SSN listed on the form. 2. MN State ID Number. For businesses located in Minnesota, enter the MN state tax identification number. ANNEX D-1 DIRECT DEPOST & W-9
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Indiana Health Coverage Programs General Instructions Please read carefully B I L L I N G P R O V I D E R U P D A T E F O R M I N S T R U C T I O N S ( F O R G R O U P S, F A C I L I T I E S, A N D S O