* This agency is requesting disclosure of your Federal Identification Number / Social Security Number in accordance with IC 4-1-8-1.
Disclosure is mandatory, and this record cannot be processed without it.
In accordance with IC 4-13-2-14.8, a person who has a contract with the State of Indiana or submits invoices to the
State of Indiana for payment shall authorize the direct deposit by electronic funds transfer of all payments by the
state to the person.
This form must be completed in order to receive payment from the State of Indiana and any time there is a change
in banking information. This form must be accompanied by a W9. If you are changing an e-mail address to
receive electronic notifications of EFT deposits, please contact email@example.com.
Change of Existing Account Prior Routing Number: ___ ___ ___ ___ ___ ___ ___ ___ ___
Prior Account Number: ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___
SECTION 1: AUTHORIZATION
According to Indiana law, your signature below authorizes the transfer of electronic funds under the following terms:
Name of Company or Individual (as shown on the account) Federal Identification Number / Social Security Number *
Address (Number and Street and/or PO Box Number) City, State, and ZIP Code (00000-0000)
SECTION 2: DIRECT DEPOSIT INFORMATION
Type of Account: Checking (Demand) Savings
Please check this box if your direct deposit will be automatically forwarded to a bank account in another country.
Financial Institution: _______________________________________________
(9 digits): ___ ___ ___ ___ ___ ___ ___ ___ ___
Account Number (maximum 17 digits – include leading zeros): ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___
SECTION 3: E-MAIL ADDRESS TO RECEIVE ELECTRONIC NOTIFICATION OF ELECTRONIC FUND
TRANSFER (EFT) DEPOSITS *Required
(Please contact firstname.lastname@example.org to add more than four addresses.)
All future notices of EFT deposits to the bank account specified above will be sent to the following e-mail addresses:
By checking this box, I authorize the information provided on this form to be accurate and I agree with the provisions on
the reverse side of this form. I also authorize the State of Indiana to initiate credit entries and to initiate, if necessary, debit
entries and adjustments for any credit entries in error to my account indicated above. This authorization will remain in effect
until the state has received written notification of its termination and has adequate time to act upon the request.
NAME (type) _____________________________________________ TITLE_____________________ TELEPHONE______________________
AUTHORIZED SIGNATURE* ___________________________________________________________ DATE (month, day, year) _______________
* Under IC 26-2-8-106, your electronic signature on this form represents the same legal authority as your written signature.
AUTOMATED DIRECT DEPOSIT
State Form 47551 (R7 / 5-18)
Approved by State Board of Accounts, 2018
Prescribed by Auditor of State, 2018
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