Transcription of Direct Deposit/Electronic Funds Transfer (EFT ...
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Direct Deposit/Electronic Funds Transfer (EFT ...
Section A: Business InformationAuthorized Account Holder s Name:Business Name:Business Address:City:State:Zip:Tax Identification Number (TIN) or SSN Used for IRS Reporting:Fax Number:Phone Number:E-mail Address:Please complete this agreement and submit it and a voided check to the address or fax number B: Bank/Financial Institution InformationName of Account (as it appears on account statement):Bank/Financial Institution Name:Bank/Financial Institution Address:City:State:Zip:Phone Number:Routing Number:Account Number:----- Please be sure to attach a voided check when you submit this form -----Signature of Authorized Account HolderSection C: Authorization StatementBy signing below, I request and authorize Delta dental of Colorado, to deposit Funds for invoice payments directly into the Bank or Financial Institution account as specified in Section B, and agree to the following:1.
That Delta Dental of Colorado may terminate this Agreement at any time without cause. Date Direct Deposit/Electronic Funds Transfer (EFT) Authorization Agreement DD/EFT Form_Pro_092710 Section D: Submission Information Send your completed form …
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