Non Payroll Direct Deposit (ACH) Enrollment Form

Exhibit J: Non Payroll Direct Deposit (AHC) Enrollment Form
National Foreclosure Mitigation Counseling Program
Round 9 Grant Agreement
DECLINES PARTICIPATION (CHECK HERE AND COMPLETE NAME ONLY): _____________
ACCEPTS (CHECK HERE AND COMPLETE FORM BELOW): ___________
PAYEE/GRANTEE INFORMATION:
1. Name: _____________________________________________________________________
2. SSN or Taxpayer ID Number: __________________________________________________
3. Street: _____________________________________________________________________
4. City & State: ________________________________________________________________
5. Zip Code: __________________________________________________________________
6. Telephone: _________________________________________________________________
7. Fax Number: ________________________________________________________________
8. Contact Name: ______________________________________________________________
9. Contact Signature & Date: ____________________________________________________
10. E-Mail Address: _____________________________________________________________
FINANCIAL INSTITUTION INFORMATION
1. Name:
2. Telephone Number:
3. Street:
4. City, State, Zip:
5. Nine Digit Routing Transit Number (ABA):
6. Account Type (Checking or Savings):
7. Account Number:
*Please attach a voided check or deposit slip.