Pokégnek Bodéwadmik • Pokagon Band of Potawatomi
DIRECT DEPOSIT FORM
Finance Department
• Box 180, Dowagiac, MI 49047
Phone (269) 462-4200 • www.PokagonBand-nsn.gov • (269) 782-6882 Fax
PAYMENT TYPE:
(Check all that apply)
EMPLOYEE ACCOUNTS PAYABLE
PER CAPITA* EDUCATION/REIMBURSEMENT
NAME/BUSINESS NAME: TRIBAL ID
ADDRESS CITY STATE ZIPCODE
PHONE#
1ST ACCOUNT-BANK NAME
ACCOUNT TYPE CHECKING SAVINGS
AMOUNT $ PERCENTAGE
ROUTING NUMBER (9 digits) ACCOUNT NUMBER:
2ND ACCOUNT-BANK NAME
ACCOUNT TYPE CHECKING SAVINGS
AMOUNT $ PERCENTAGE
ROUTING NUMBER (9 digits) ACCOUNT NUMBER:
3RD ACCOUNT-BANK NAME
ACCOUNT TYPE CHECKING SAVINGS
AMOUNT $ PERCENTAGE
ROUTING NUMBER (9 digits) ACCOUNT NUMBER:
Complete and return to the Finance department. Please be sure to submit a voided check
or bank letter showing the account and routing numbers for any account distributions.
I, ______________________________________authorize the above on _____________ (Date)
(Print Name)
_______________________________________________________ Date ____________
(Signature)
* Per Capita must be in by the deadline for changes for test-run on account. Banking information errors
will result in a check being sent by mail.
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or
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