ESBD_551185_1787086946965_Form 4 - Direct Deposit Form.pdf

TWC1020 (06/18) Page 1 of 2

TWC Direct Deposit Form

Box 1

Box 2

Box 3

Legal Name (as shown on your tax return):

Business Name (if different from Box 1):

Tax Information Mailing Address:

City: State: Zip:

Phone: Fax: Email:

Box 4 Payment Address (if different from Tax Address):

City: State: Zip:

Phone: Fax: Email:

Box 5 Taxpayer Identification Number:

Note: Enter the same number used filing your tax return Social Security Number (SSN) Employer Identification Number (EIN)

Box 6 Federal Tax Classification/ Business Designation:

T=Texas Corporation; C=Professional Corporation; or T/O= Limited Liability Company

A=Professional Assoc. I=Individual Recipient L=Limited Partnership F=Financial Institution P=General Partnership R=Foreign Corporation O=Out-of-State Corporation U=State Agency/University S=Sole Owner E=State Employee G=Government Entity N= Other

If Other, please explain:

Box 7 Profit Status: Profit Non-Profit

Box 8 Corporation Info: State of Jurisdiction: File or Charter Number:

Box 9 Sole Ownership Info: Sole Owner Name:

Sole Owner SSN:

Box 10 General Partnership Information:

Partner 1 Name:

Partner 1 SSN/EIN:

Partner 2 Name:

Partner 2 SSN/EIN:

Box 11 Backup Withholding:

Please see IRS Website

Exempt from Backup Withholding

TWC1020 (06/18) Page 2 of 2

Direct Deposit Information (Response Required) Box 12 New Account Information (Setups and Changes)

I am currently on Direct Deposit and wish to continue. I decline Direct Deposit at this time.

New Set-up Change in Direct Deposit Information Cancel My Direct Deposit

Financial Institution Name:

Financial Institution Address: City: State: Zip:

Financial Institution Routing Number: Type of Account:

Account Number: Checking Savings Box 13 Existing Account Information (Complete only for direct deposit information change)

Financial Institution Routing Number: Type of Account:

Account Number: Checking Savings Box 14

Box 15 Will payments be forwarded to a financial institution outside the United States? Yes No

Certification of TWC Substitute W-9 and Direct Deposit Form Under penalties of perjury, I certify that:

1) I have provided my correct taxpayer identification number and that;

2) I am not subject to backup withholding as specified on the instruction page for this form and that;

3) I am a US citizen or other US person and that;

4) For Direct Deposit Authorization Setup, Changes or Cancellation I authorize the Texas Comptroller of Public Accounts to deposit my payments from the State of Texas to my financial institution electronically. I understand that the Texas Comptroller of Public Accounts will reverse any payments to my account in error.

I further understand that the Texas Comptroller of Public Accounts will comply at all times with the National Automated Clearing House Association’s rules. For further information on these rules, please contact your financial institution.

Authorized Signature Required:

Printed Name Required: Date Required: