Transcription of Direct Deposit/Electronic Funds Transfer (EFT ...
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Direct Deposit/Electronic Funds Transfer (EFT ...
Direct Deposit/Electronic Funds Transfer (EFT) Authorization AgreementSECTION A InstructionsPlease complete Sections B, C and D and return this Direct Deposit/Electronic Funds Transfer (EFT) AuthorizationAgreement ( Agreement ) along with a voided check to OR by mailing to the following address:Attention: AccountingDelta dental of ColoradoPO Box 5468 Denver, CO 80217-5468 SECTION B Business Information- Please type or printAuthorized Account Holder s Name Business Entity Name Business Address City State Zip Business Tax Identification Number (EIN or SSN - used for IRS reporting) Phone Number Fax Number E-mail Address SECTION C Bank or Financial Institution Information- Please attached a voided of Account (as it appears on checking account) Bank or Financial Institution Name Phone Number Address City State Zip Business Tax Identification Number (EIN or SSN - used for IRS reporting)
The effective date for electronic funds transfer will be at least fifteen (15) days from the date Delta Dental of Colorado receives the completed and signed Agreement; 2.
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