Wisconsin Direct Deposit Form 2

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REQUEST FOR DIRECT DEPOSIT
Please read the instructions on the reverse side before completing this form.
Section I – IDENTIFICATION
Requested Effective Date (MM DD CCYY)
Tab to start / continue
Name of Taxation District
Town
City
Village
County
County - Municipal Code
Street Address
City
IPAS Account Number
StateZip
Section II – ACCOUNT INFORMATION
Choose Option A or B
Option A – Local Financial Institution
CURRENT OR 1ST TIME
Name of Financial Institution
REQUESTED CHANGE
Name of Financial Institution
Branch (if any)Branch (if any)
Street Address
Street Address
City
StateZip
Bank Routing Number (9‑digits)
Type of Account
Checking
City
StateZip
Bank Routing Number (9‑digits)
Account Number
Type of Account
Savings
Checking
Signature of Bank Official
Account Number
Savings
Date Signed (MM DD CCYY)
Phone Number
() –
Option B – Local Government Pooled Investment Fund
Local Government Pool Number
Local Government Pool Number
Sub-Account Number
Sub-Account Number
Routing Number
STATE USE ONLY
Signature – State Treasurer’s Office
Depositor Acct. No.
Routing Number
STATE USE ONLY
Depositor Acct. No.
STATE USE ONLY
Date Signed (MM DD CCYY)
STATE USE ONLY
Phone Number
() –
Section III – CERTIFICATION I HEREBY AUTHORIZE the State of Wisconsin, hereinafter called STATE, to deposit directly to the
organization’s account at the depository named above or the Local Government Pooled Investment Fund administered through the Office of the State
Treasurer, hereinafter called DEPOSITORY, to credit same to such account. The STATE is authorized to verify data directly with the DEPOSITORY.
I also authorize the State of Wisconsin to make debit adjustments to the same account to correct problems or errors. This authority is to remain in
full force and effect until STATE has received written notification from this organization to change the designated depository in such time and in
such manner as to afford STATE and DEPOSITORY a reasonable opportunity to act on it.
Print or Type Name
Title
Signature
Date (MM DD CCYY)
Contact Person’s Name
Email
Telephone Number
() –
SL-201 (R. 9-12)
Wisconsin Department of Revenue
INSTRUCTIONS
1. Section I – Identify taxation district/county submitting this form. Include 2‑digit county code and 3‑digit
municipal code. For counties, your municipal code is 999. Also include your 4‑digit IPAS account
number, if known.
2. Section II – Choose either option “A” or “B.”
Complete left-hand column of form to identify current or first request information.
Complete right-hand column to show new/revised information.
2a.
If option “A” is chosen: Take this form to your bank and secure a signature from a bank official
verifying accuracy of the town, village, city, or county’s account number.
2b.
If option “B” is chosen: Send completed form directly to the Department of Revenue and we
will obtain account verification from the State Treasurer. You must be a member of the Local
Government Pooled Investment Fund before selecting Option B. Contact the Office of the State
Treasurer for details.
3. Section III – Sign and date the form. Enter contact person and telephone number.
4. If selecting a checking account as the deposit account, please void and attach a blank check for the
applicable account.
5. If you have questions regarding this form contact us at (608) 261‑5374 or (608) 264‑6892.
Mail completed form to:
Fax: (608) 264-6887
Bureau of Local Government Services, 6-97
Wisconsin Department of Revenue
PO Box 8971
Madison WI 53708-8971