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authorization agreement for direct Deposit Agency InformationBank InformationImportant Note: Please forward this completed form only when you are ready to submit your first piece of business. All the fields must be filled in completely before to BTIS DirectPay at or fax to (818) 914-2611. Agency NameAgency CodeBank NameAgency AddressBank AddressBank Account NameAgency Principal Name (Print)Agency Principal EmailDateAgency Principal SignatureCityCityAccount NumberEmail for Receiving StatementsI authorize BTIS DirectPay to deposit proceeds with the financial institution I have indicated. The financial institution is authorized to credit those funds to the account indicated. The authority will remain in effect until I have given 30 days written notice of its termination or until BTIS DirectPay or my financial institution has given me 10 days notice that this direct deposit has been terminated.

Authorization Agreement for Direct Deposit Agency Information Bank Information Important Note: Please forward this completed form only when you are ready to submit your first piece of business.

  Form, Agreement, Direct, Authorization, Deposits, Authorization agreement for direct deposit

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