I would like to: r Add r Delete Type: r ACH r Wire
STAR Ohio Account Number(s) ______________________________________________________
Name of Municipality ______________________________________________________
Financial Institution Name ______________________________________________________
Account Number ______________________________________________________
Financial Routing/ ABA Number ______________________________________________________
Account Type (select one): r Checking r Savings
For Further Credit (FFC/FBO) optional ______________________________________________________
Activate these instructions for online use: r Yes r No
This authorization will remain in force and effective until STAR Ohio receives written notication by an individual
authorized to direct changes on behalf of the account.
Authorized Signature ___________________________________________________________________________
Federal ID Number ______________________________________________ Date _______________________
Submit the signed instruction authorization agreement to STAR Ohio Client Services by mail or fax:
Mailing Address: STAR Ohio Fax: (614) 923-1149
P.O. Box 7177
6125 Memorial Drive
Dublin, OH 43017
Please call STAR Ohio Client Services at (800) 648-STAR (7827) with questions regarding this form.
ACH or Wire Banking Instructions
Authorization Agreement
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