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VENDOR AUTHORIZATION AGREEMENT FOR ACH PAYMENT

VENDOR AUTHORIZATION AGREEMENT FOR ACH PAYMENT Directions Type or print the information requested in Sections 1 and 2. Then sign, date, and return the form with your VENDOR package. Any account changes must be reported to DCA within ten (10) days prior to actual change. A payee must keep DCA informed of any address changes in order to receive important information about benefits and to remain qualified for payments. Please refer to the application instructions, if applicable. Section 1 - Entity to Receive Direct Deposit Type of Transaction: Add Change Delete Name of Company OR Individual County Telephone Street Address City State Zip

VENDOR AUTHORIZATION AGREEMENT FOR ACH PAYMENT . Directions • Type or print the information requested in Sections 1 and 2. Then sign, date, and return the form with your Vendor package. • Any account changes must be reported to DCA withinten (10) days prior to actualchange. A payee must keep DCA

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