ELECTRONIC FUND TRANSFER/PAYMENT ENROLLMENT FORM

FOR NHHFA USE ONLY
PAYEE ID:
EFT ID:
ELECTRONIC FUND TRANSFER/PAYMENT
ENROLLMENT FORM
This form is used for establishing Automated Clearing House (ACH) payments with New Hampshire Housing.
PRIVACY ACT STATEMENT
The following information is provided to comply with the Privacy Act of 1974 (P.L. 93-579).
PAYER/COMPANY INFORMATION
NAME:
ADDRESS:
New Hampshire Housing Finance Authority
P.O. Box 5087
Manchester, NH 03108
CONTACT PERSON NAME:
Assisted Housing Division
ADDITIONAL INFORMATION:
TELEPHONE NUMBER:
(800) 439-7247
NEW / EXISTING
NAME/COMPANY INFORMATION
NAME:
SSN NO. OR TAXPAYER ID NO.
ADDRESS:
CONTACT PERSON NAME: (if different from above)
DATE:
TELEPHONE NUMBER:
E-MAIL ADDRESS:
SIGNATURE:
TITLE OF AUTHORIZED OFFICIAL: (for businesses only)
In signing this form, I authorize all payments to be sent to the bank/financial institution named below for
deposit to the designated account.
BANK/FINANCIAL INSTITUTION INFORMATION
NAME:
ADDRESS:
BANK/FINANCIAL INSTITUTION REPRESENTATIVE NAME: (if available)
TELEPHONE NUMBER:
NINE-DIGIT ROUTING TRANSIT NUMBER:
BANK/FINANCIAL INSTITUTION ACCOUNT NAME:
BANK/FINANCIAL INSTITUTION ACCOUNT NUMBER:
TYPE OF ACCOUNT:
[ ] CHECKING
[ ] SAVINGS
Instructions for Completing
Electronic Fund Transfer/Payment Enrollment Form
Complete the entire form. Original forms including original signatures must be received in
order to be processed. Please contact our Assisted Housing Division at 1-800-439-7247 with
questions.
Payee/company keeps one copy. Mail original to:
New Hampshire Housing Finance Authority
Attn: Assisted Housing Division
P.O. Box 5087
Manchester, NH 03108
1. Payer/Company Information
•
This section is filled out by New Hampshire Housing
2. Name/Company Information
•
•
Print or type your name or your company’s name and address, social security number or
taxpayer ID number, contact person name, telephone number and e-mail address.
Your signature and title or the signature and title of an authorized official of your
company to receive electronic payments must be included. Please include a valid email
address in order to receive a monthly itemized statement for Section 8 payments.
3. Bank/Financial Institution Information
•
•
•
•
•
Print or type the name and address of your (or your company’s) bank or financial
institution who will receive the electronic payments. Please include a contact name and
phone number of someone at your bank or financial institution.
Fill in the nine-digit routing transit number which is your bank’s or financial institution’s
ABA number.
Bank/Financial Institution Account Name: Print the name that is listed on your bank
account.
Bank/Financial Institution Account Number: Print the account in this space. If you have a
personal bank account, the name of the account is usually your own name.
Type of Account: Please check whether the account is a checking or saving