EFT Authorization Form.pdf

86 KB Posted

Attached to
Fisheries Specialist
Solicitation number
25CRDFBPPAYT-0091
Issued by
Polk County, Des Moines City, Iowa

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Written by GovTribe AI ·

This is a Direct Deposit Authorization Form issued by the State of Iowa's Department of Administrative Services for electronic funds transfer (EFT) payments. The form allows vendors and contractors receiving payments from the State of Iowa to authorize direct deposit of funds into designated financial institution accounts. The form accommodates three transaction types: adding a new EFT authorization, changing existing banking information, or canceling the agreement to revert to state warrant payments. Vendors must complete all required sections including business or individual identification information, banking details, and authorized representative signatures. Changes to EFT status become effective ten business days after entry into the state's accounting system, while cancellations take effect immediately. The completed form should be submitted to the Department of Administrative Services-State Accounting Enterprise, Hoover State Office Building, 3rd Floor, Des Moines, Iowa 50319, either by mail or fax to (515) 281-0246.

The form requires vendors to provide either a voided check, enrollment confirmation for prepaid cards, or a bank account verification letter from the financial institution. The financial institution representative must verify signature authenticity and account numbers and confirm ACH capability and NACHA compliance. Vendors authorize the State of Iowa to initiate adjustments or debit entries for erroneous deposits and acknowledge that the state can only deposit funds into one financial institution and account per vendor. This authorization form is essential for contractors under state and local contracts, including those for the Fisheries Specialist position with the Iowa Department of Natural Resources, to receive timely payment of wages and contract funds through direct deposit.

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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

SSN:
FEIN:
Trans Type: Off
Accnt Type: Off
Date:
Phone Number:
Legal Business / Individual Name:
Business Name:
Mailing Address:
City:
State:
Zip:
City_2:
State_2:
Zip_2:
Name on Accnt:
Routing Trans Number:
Customer Accnt Number:
Old Routing Number:
Old Account Number:
Representative Name:
Representative Title:
Authorized Name:
Title:
Date_2:
Phone Number_2:
Fin Inst Name:
Fin Inst Address:

File details come from the government source that posted it. Updated .