Transcription of Authorization Agreement For Electronic Funds Transfer
1 Authorization Agreement FOR Electronic Funds Transfer (SCO EFT-1) Complete Section I Below: Please Check Ap propriate Boxes HOLDER INFORMATION FEDERAL EMPLOYER ID# (FEIN): NAME ADDRESS CITY UNCLAIMED PROPERTY HOLDER TYPE CODE New ACH Registration Change EFT Remittance Method ---Change Holder Contact Information ---lSTATE I1--I PHONE I ( ) CONTACT INFORMATION {for EFT Registration) NAME EMAIL PHONE ----I ZIP--EXT I ----( ___ ) ___ -____ IEXT I I FAX !( ___ )-----Complete Section II, Ill or IV Below: SECTION II I ACH DEBIT0 I have verified our company's Financial Institution can originate an ACH Debit transaction in the required record field. SIGNATURE: TITLE DATE SECTION Ill I ACH CREDIT I have verified our company's Financial Institution can originate an ACH Credit transaction in the required record : TITLE DATE SECTION IV I INTERNATIONAL Funds TRANSFERSIGNATURE TITLE DATE For EFT assistance Call (916) 464-6220 or Email Return this completed EFT-1 Form by: Fax to (916) 464-6224, Email to or mail toState controller 's Office, Unclaimed Property Division, Attention: EFT Desk Rev.}
2 05/2017 Box 942850, Sacramento, CA 94250-5873 1of2
