EFT Authorization Form.pdf
PDF 86 KB Posted
- Attached to
- Equipment Distribution Program
- Solicitation number
- 005-RFP-1302-2025
- Issued by
- Polk County, Des Moines City, Iowa
About this file
This is a Direct Deposit Authorization Form issued by the State of Iowa's Department of Administrative Services (DAS) for vendors conducting business with the state. The form serves as the mechanism for state entities to establish, modify, or terminate electronic funds transfer (EFT) agreements for payment disbursement. Vendors must complete the form to authorize the State of Iowa to deposit contract payments directly into a designated financial institution account. The authorization remains in effect until canceled by the payee, with new or modified EFT arrangements becoming effective ten business days after entry into the state's accounting system, while cancellations take effect immediately. Vendors are responsible for notifying the state when accounts are closed and must submit a new form for any changes to banking information.
To process the authorization, vendors must provide one of three supporting documents: a voided check, pre-paid card enrollment confirmation, or a bank account verification letter from the financial institution. The financial institution must verify the signature and account information and confirm ACH capability and compliance with NACHA rules. The vendor authorization certifies that the state can only deposit funds into a single financial institution and account per vendor agreement and that the state may initiate adjustments or debit entries to recover erroneous deposits. The completed form should be mailed or faxed to the DAS State Accounting Enterprise, Hoover State Office Building, 3rd Floor, Des Moines, Iowa 50319, with contact available at (515) 281-5255 or (515) 281-0246.
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Text version
Direct Deposit Authorization Form
SECTION 1 – TRANSACTION TYPE
ARE YOU ADDING, CHANGING OR CANCELING THIS AGREEMENT? ADD CHANGE CANCEL
1) The agreement represented by this authorization remains in effect until canceled by the payee and until such time, payments made by the
State of Iowa to you will be deposited into the account at the financial institution designated below.
2) You are required to submit a new form for any change in banking designation or to cancel this authorization and revert to a state warrant.
3) It is your responsibility to notify the State of Iowa any time an account is closed.
4) An add or change in EFT status will be effective ten business days after entry into the State's accounting system.
5) A cancelation will become effective immediately after entry into the State's accounting system.
SECTION 2 – BUSINESS / INDIVIDUAL IDENTIFICATION INFORMATION
BUSINESS / INDIVIDUAL LEGAL NAME
Name Tax ID is Assigned To and Used for Tax Reporting
BUSINESS NAME
DBA (Doing Business As) If Different than Legal Name
SSN OR FEIN
Social Security Number Federal Employee ID Number
MAILING ADDRESS
Address to be used in case of Default to Check
CITY STATE ZIP
SECTION 3 – BANKING INFORMATION
1) A voided check or copy of enrollment confirmation if a pre-paid card, or Section 3 requires one of three items: 2) The financial institution must complete the representative box within Section 3, or
3) The financial institution must supply a bank account verification letter.
FINANCIAL INSTITUTION NAME
FINANCIAL INSTITUTION ADDRESS
CITY STATE ZIP
NAME ON ACCOUNT ACCOUNT TYPE:
ROUTING TRANSIT NUMBER SAVINGS
CUSTOMER ACCOUNT NUMBER CHECKING
REQUIRED IF REQUESTING A CHANGE:
OLD Routing Number: OLD Account Number
I have verified the signature(s) and account numbers above. The Financial Institution is ACH capable and will comply with NACHA rules.
REPRESENTATIVE NAME REPRESENTATIVE TITLE
SIGNATURE
DATE PHONE NUMBER
SECTION 4 – REQUIRED VENDOR AUTHORIZATION FOR ADD, CHANGE OR CANCELATION
I hereby authorize the Department of Administrative Services to deposit payments from the State of Iowa to the account designated on this form and to initiate any adjustments or debit entries to this account for any erroneous deposits in the amount of the error only. I also understand that the State of Iowa can only deposit funds into one financial institution and account.
I certify that I am authorized to enter into this agreement as the account holder or on behalf of the account holder.
AUTHORIZED NAME TITLE DATE
SIGNATURE PHONE NUMBER
Mail or Fax Completed Form to: Dept. Admin Services-State Accounting Enterprise Attn: EFT Coordinator Fax Number Hoover State Office Building, 3rd FL Phone Number
(515) 281-5255 Des Moines, Iowa 50319 (515) 281-0246 Updated 07/2014
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