Indiana Direct Deposit Form 3

Add Deposit
Change Deposit
Stop Deposit
Name of Vendor/Claimant who prepared this Request
Work Number:
State Form 47551 (2/96)
Name:
Approved by State Board of Accounts 09/1997
Home Number:
STATE OF INDIANA
AUTOMATED DIRECT DEPOSIT AUTHORIZATION AGREEMENT
1.
2.
3.
4.
Instructions:
Requestor will complete first section and have their bank/credit union complete Section 2.
The bank/credit union will complete Section 2 and return to the requestor.
Requestor will file completed form with Auditor of State, 200 West Washington St., Room 240, Indianapolis, IN 46204-2728
Requestor and depository should retain a copy. Additional blank copies are available from Auditor of State. Phone: (317) 232-3300
SECTION 1:
REQUEST AND AUTHORIZATION
,
Vendor / Claimant as shown on the account
Federal I.D. Number / Social Security Number
,
Address (Number and Street, and/or P.O. Box No.)
City, State, and Zip Code (00000-0000)
requests, pursuant to IC 4-8.1-2-7(d), to receive payment(s) by means of an electronic transfer of funds, and authorizes the
same under the terms stated herein.
It is understood by the undersigned Vendor/Claimant that, if approved, the Auditor of State may authorize the
Treasurer of State to: (1) initiate credit (deposits) in various and varying amounts, by electronic transfer of funds through
automated clearing house (ACH) processes, to the below listed checking (demand) or savings account designated in the
depository named below, and, (2) if necessary , to initiate debit entries or adjustments solely to correct any credit error
resulting from a deposit/credit entry that was made under this authorization . The Vendor/Claimant may revoke or cancel
this request and authorization by notifying the Auditor of State in writing at least fifteen (15) days prior. Any change to the
account or to a new financial institution will require a new State of Indiana Automated Direct Deposit Authorization
Agreement. Failure to timely notify the Auditor of an account change will delay payment.
Name of Depository:
Checking (Demand)
Type of Account:
Savings
Depository Account Number:
Date
SECTION 2:
, 20
Signature of Vendor / Claimant
DEPOSITORY'S APPROVAL
The above is satisfactory and the undersigned designated depository agrees to accept such automated deposits.
Name of Depository:
Phone:
(
)
Address:
(Number and Street, and/or P.O. Box No.)
Date
, 20
ABA Transit-Routing Number
(City, State, and Zip Code (00000-0000)
Depository's Authorized Signature
Title