Exhibit D EFT Authorization Form 082017.pdf

rev 08/2017

EFT DIRECT DEPOSIT

AUTHORIZATION FORM

SECTION I (DEPARTMENT USE) - PAYOR, STATE INFORMATION

STATE DEPARTMENT VCUST#

MAILING ADDRESS ADDRESS ID

CITY, STATE, ZIP VERIFIED BY

DEPARTMENT CONTACT

EMAIL PHONE

SECTION II – PAYEE, VENDOR INFORMATION

VENDOR NAME

D/B/A (DOING BUSINESS AS, OPTIONAL)

MAILING ADDRESS

CITY, STATE, ZIP

EMAIL (FOR REMITTANCE ADVICE) PHONE

SECTION III – DEPOSITORY FINANCIAL INSTITUTION AND ACCOUNT INFORMATION

INCLUDE A VOIDED CHECK (NOT A TEMPORARY CHECK OR DEPOSIT SLIP) OR SIGNED

BANK LETTER THAT INCLUDES ALL INFORMATION REQUESTED IN THIS SECTION

BANK NAME BRANCH ADDRESS

ROUTING NUMBER ACCOUNT NUMBER

ACCOUNT TYPE CHECKING SAVINGS FOR FURTHER CREDIT (OPTIONAL)

PAYEE TAXPAYER ID (SSN/EIN)

SHOULD ALL PAYMENTS TO THIS TAXPAYER ID USE THIS BANK ACCOUNT? YES NO

IF NO, PLEASE EXPLAIN

SECTION IV – AUTHORIZATION FOR DIRECT DEPOSIT SET UP, CHANGE, OR CANCEL

SET UP CHANGE CANCEL FOR CHANGES ONLY, PLEASE PROVIDE EXISTING ROUTING & ACCOUNT NUMBER

ROUTING NUMBER EXISTING ACCOUNT NUMBER

I certify that I have the authority to execute this authorization. I herby authorize the State of Colorado to initiate, change, or cancel EFT credit entries (deposits) and if necessary to reverse any incorrect EFT payments made in error to the bank account indicated above. In the event a reversal cannot be implemented, I understand the State will utilize any other lawful means to recover the deposited funds to which the payee was not entitled. This authorization is to remain in full force until the State has received written notification of cancellation in such time as to afford a reasonable opportunity to act on it.

PRINTED NAME TITLE

SIGNATURE DATE