Direct Deposit Form.pdf

AUTOMATED DIRECT DEPOSIT

AUTHORIZATION AGREEMENT

State Form 47551 (R10 / 12-24) Approved by State Board of Accounts, 2018 Prescribed by State Comptroller, 2024

* This agency is requesting disclosure of your Federal Identification Number / Social Security Number in accordance with IC 4-1-8-1.

Disclosure is mandatory, and this record cannot be processed without it.

In accordance with IC 4-13-2-14.8, a person who has a contract with the State of Indiana or submits invoices to the State of Indiana for payment shall authorize the direct deposit by electronic funds transfer of all payments by the state to the person.

This form must be completed in order to receive payment from the State of Indiana and any time there is a change in banking information. This form must be accompanied by a W9. If you are changing an e-mail address to receive electronic notifications of EFT deposits, please contact suppliers@comptroller.in.gov.

New Enrollment

Change of Existing Account Prior Routing Number: ___ ___ ___ ___ ___ ___ ___ ___ ___ Prior Account Number: ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___

SECTION 1: AUTHORIZATION

According to Indiana law, your signature below authorizes the transfer of electronic funds under the following terms:

Name of Company or Individual (as shown on the account) Federal Identification Number / Social Security Number *

Address (Number and Street and/or PO Box Number) City, State, and ZIP Code (00000-0000)

SECTION 2: DIRECT DEPOSIT INFORMATION

Type of Account: Checking (Demand) Savings

Financial Institution: _______________________________________________

Routing Number (9 digits): ___ ___ ___ ___ ___ ___ ___ ___ ___

Account Number (maximum 17 digits – include leading zeros): ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___

SECTION 3: E-MAIL ADDRESS TO RECEIVE ELECTRONIC NOTIFICATION OF ELECTRONIC FUND

TRANSFER (EFT) DEPOSITS *Required (Please contact suppliers@comptroller.in.gov to add more than four addresses.)

All future notices of EFT deposits to the bank account specified above will be sent to the following e-mail addresses:

By checking this box, I authorize the information provided on this form to be accurate and I agree with the provisions on the reverse side of this form. I also authorize the State of Indiana to initiate credit entries and to initiate, if necessary, debit entries and adjustments for any credit entries in error to my account indicated above. This authorization will remain in effect until the state has received written notification of its termination and has adequate time to act upon the request.

NAME (type) _____________________________________________ TITLE_____________________ TELEPHONE______________________

AUTHORIZED SIGNATURE* ___________________________________________________________ DATE (month, day, year) _______________

* Under IC 26-2-8-106, your electronic signature on this form represents the same legal authority as your written signature.

INSTRUCTIONS:

1. Complete all three sections and sign and date the bottom of the form.

Note: If signing electronically, the form must be saved first, and then opened in Adobe Acrobat. For help in creating a digital ID please click here.

2. File the completed form with the agency that you do business with.

3. Retain a copy of the completed form for your records.

By Signing This Form:

You are responsible for ensuring this form is filled out legibly. You are also responsible for ensuring that this form was approved and instructions above are followed. By signing this form, you represent that it is understood by all parties that, if approved:

1. The State of Indiana must initiate credits (deposits) in various amounts, by electronic transfer of funds through automated clearing house (ACH) processes, to the listed checking (demand) or savings account designated in the financial institution named in Section 2.

2. If necessary, you will accept reversals from the State for any credit entries made in error to the bank account per National Automated Clearing House Association (NACHA) regulations.

3. You may only revoke this request and authorization by notifying the State Comptroller by e-mailing suppliers@comptroller.in.gov or in writing at the following address: Indiana State Comptroller, 200 W. Washington St. Ste 240, Indianapolis, IN 46204. The authorization will remain in effect until the office has adequate time to act upon the request.

4. A new Automated Direct Deposit Authorization Agreement is required for change in existing account information. The previous account information must be provided. Failure to timely notify the State Comptroller of an account change will delay payment.

5. The State of Indiana and its entities are not liable for late payment penalties or interest if you fail to provide information necessary for an electronic funds transfer and/or you do not properly follow these Instructions.

6. E-mail address(es) must be provided in Section 3 to allow for appropriate application of all payments through Electronic Notification.

7. You acknowledge that it will cause disruption to the notification process if the e-mail addresses provided for electronic funds transfer notification are frequently changed or changed without promptly providing an updated e-mail address to the State Comptroller.

8. You acknowledge that an e-mail notification returned as undeliverable may be removed from the State Comptroller’s e-mail notification system.

9. You are responsible for contacting the State Comptroller if you are not receiving electronic notices of EFT deposits.