Arizona Direct Deposit Form 2

UIB-1091A FORFF (12-09)
Instructions
ARIZONA DEPARTMENT OF ECONOMIC SECURITY
Unemployment Insurance Administration
INFORMATION REGARDING DIRECT DEPOSIT
PLEASE READ CAREFULLY – Improper submissions may delay the direct deposit process.
Direct deposit is the electronic transfer of your weekly unemployment benefit payment into your bank account.
This method of payment is an alternative to the Electronic Payment Card (debit card). When you sign up for
direct deposit, you are giving the Department of Economic Security permission to credit your bank account.
To sign up for direct deposit, complete the application form on the next page. The form is interactive—you can
complete it on your PC and print it. In order to process your request for direct deposit, you must provide the
bank routing and account numbers from the financial institution where the account is maintained. These
codes are printed on your checks. For direct deposits into either a checking or savings account a blank
check with “VOID” written across the front must be mailed with your completed form. If you do not have a
blank check, you must have your financial institution complete Section A of the Agreement for Direct Deposit
form (on page two).
DO NOT SEND A DEPOSIT SLIP
Deposit slips do not have the necessary codes to set up direct deposit and will not be accepted.
Submitting anything other than a voided check or the completed
Section A of the Agreement for Direct Deposit form will delay the process.
Mail your completed application along with a voided check or Section A of the Agreement for Direct Deposit
form completed by your financial institution to:
Arizona Department of Economic Security
UI Administration
PO Box 21106
Phoenix AZ 85036-1106
IMPORTANT NOTE: The above address is to be used only for mailing direct deposit forms. If you send other
correspondence or materials to this address, it could delay receipt by the party for whom it is intended.
Direct deposits generally begin 10 days after we receive your application and voided check. You will continue to
receive any benefit payments you are entitled to by check during this period.
Payments are usually posted to your account two working days after the funds are transferred. You can see
when your payment was transferred by accessing AZUI.com, selecting “View UI Claim Information” from the
“Online Services” menu on the left of the page. When you reach the main page of the online claim filing system,
select “View Claim Information” from the drop-down menu. If you choose to file your weekly claims by
telephone using TIPS (Telephone Information and Payment System), payment inquiries are available through
Option 2. You will need to contact your bank or credit union to determine when the benefit payment is actually
posted to your checking or savings account.
If there are any changes to your bank or credit union account, you must notify us immediately.
Changes to your bank or credit union account must be provided in writing to the address shown above. A new
form must be completed and mailed to the Department if you close or change your checking or savings account.
If you change your account and wish to continue with direct deposits, you must include a voided check from
the new account, or a completed Section A, on a new Agreement for Direct Deposit. The reported change
will be verified with your bank or credit union. This verification will take approximately 10 days and you will
receive any benefit payments made during this time by check. If you wish to terminate your direct deposit, you
must complete a Cancellation of Direct Deposit (ESA-1126A) form. Forms can be accessed on-line at AZUI.com.
Equal Opportunity Employer/Program. • Under Titles VI and VII of the Civil Rights Act of 1964 (Title VI and VII), and the
Americans with Disabilities Act of 1990 (ADA), Section 504 of the Rehabilitation Act of 1973, and the Age Discrimination Act of
1975, the Department prohibits discrimination in admissions, programs, services, activities or employment based on race,
color, religion, sex, national origin, age, and disability. The Department must make a reasonable accommodation to allow a
person with a disability to take part in a program, service or activity. Auxiliary aids and services are available upon request to
individuals with disabilities. For example, this means if necessary, the Department must provide sign language interpreters for
people who are deaf, a wheelchair accessible location, or enlarged print materials. It also means that the Department will take
any other reasonable action that allows you to take part in and understand a program or activity, including making reasonable
changes to an activity. If you believe that you will not be able to understand or take part in a program or activity because of
your disability, please let us know of your disability needs in advance if at all possible. To request this document in alternative
format or for further information about this policy, contact your local office manager TTY/TDD Services: 7-1-1. • Disponible en
español.
ARIZONA DEPARTMENT OF ECONOMIC SECURITY
Unemployment Insurance Administration
UIB-1091A FORFF (12-09) – Page 2
AGREEMENT FOR DIRECT DEPOSIT
MAIL TO:
Arizona Department of Economic Security
UI Administration
PO Box 21106
Phoenix AZ 85036-1106
Direct Deposit Agreements will only be accepted by mail. DO NOT fax or e-mail completed forms.
APPLICANT’S NAME (Print or type)
SOCIAL SECURITY NUMBER
I authorize the Arizona Department of Economic Security, Unemployment Insurance Administration, to make
automatic deposit of the full amount of any payments of my weekly unemployment benefits to my:
Checking Account
Savings Account
I authorize the Arizona Department of Economic Security, Unemployment Insurance Administration, to change
the automatic deposit of any payments of my unemployment benefits to my:
Checking Account
Savings Account
ATTACH VOIDED CHECK FROM YOUR CHECKING OR SAVINGS ACCOUNT HERE
If a voided check is not available: take this form to your bank or credit union, have a representative complete
Section A below. Mail the completed form to the address shown above.
SECTION A
NAME AND ADDRESS OF FINANCIAL INSTITUTION
ROUTING NUMBER








ACCOUNT NUMBER
FINANCIAL INSTITUTION CERTIFICATION
As representative of the above-named financial institution, I confirm the identity of the payee, the routing and account numbers.
REPRESENTATIVE’S NAME (Print or type)
REPRESENTATIVE’S SIGNATURE
TELEPHONE NUMBER
DATE
I understand that the Arizona Department of Economic Security, UI Administration, can automatically deposit
unemployment benefits only to a separate or joint banking account under which the name of the above individual is listed.
I understand that is my own responsibility to verify any such deposits of UI benefits with my banking institution.
This authorization shall remain in effect until the Arizona Department of Economic Security has received written
notification from me to terminate or otherwise change the automatic deposit of my unemployment benefits. Such
notification shall be delivered in a timely manner in order to afford the Arizona Department of Economic Security an
opportunity to comply. In no event shall any such termination or change affect any unemployment benefits previously
processed or being processed by the Arizona Department of Economic Security for automatic deposit at the time of
receipt of my notification.
In the event of an error in the automatic deposit of my unemployment benefits to my account, I authorize my named
banking institution to correct the error in my account. I understand that if an error is made, I shall receive written
notification from the Arizona Department of Economic Security with an explanation of such error.
I authorize my banking institution to release to the Arizona Department of Economic Security any account
information pertaining to my receipt and eligibility for Unemployment Insurance benefits.
APPLICANT”S SIGNATURE
DATE