Direct Deposit Authorization Form
SECTION 1 – TRANSACTION TYPE
ARE YOU ADDING, CHANGING OR CANCELING THIS AGREEMENT? ADD CHANGE CANCEL
1) The agreement represented by this authorization remains in effect until canceled by the payee and until such time, payments made by the
State of Iowa to you will be deposited into the account at the financial institution designated below.
2) You are required to submit a new form for any change in banking designation or to cancel this authorization and revert to a state warrant.
3) It is your responsibility to notify the State of Iowa any time an account is closed.
4) An add or change in EFT status will be effective ten business days after entry into the State's accounting system.
5) A cancelation will become effective immediately after entry into the State's accounting system.
SECTION 2 – BUSINESS / INDIVIDUAL IDENTIFICATION INFORMATION
BUSINESS / INDIVIDUAL LEGAL NAME
Name Tax ID is Assigned To and Used for Tax Reporting
BUSINESS NAME
DBA (Doing Business As) If Different than Legal Name
SSN OR FEIN
Social Security Number Federal Employee ID Number
MAILING ADDRESS
Address to be used in case of Default to Check
CITY STATE ZIP
SECTION 3 – BANKING INFORMATION
1) A voided check or copy of enrollment confirmation if a pre-paid card, or
Section 3 requires one of three items: 2) The financial institution must complete the representative box within Section 3, or
3) The financial institution must supply a bank account verification letter.
FINANCIAL INSTITUTION NAME
FINANCIAL INSTITUTION ADDRESS
CITY STATE ZIP
NAME ON ACCOUNT ACCOUNT TYPE:
ROUTING TRANSIT NUMBER SAVINGS
CUSTOMER ACCOUNT NUMBER CHECKING
REQUIRED IF REQUESTING A CHANGE:
OLD Routing Number: OLD Account Number
I have verified the signature(s) and account numbers above. The Financial Institution is ACH capable and will comply with NACHA rules.
REPRESENTATIVE NAME REPRESENTATIVE TITLE
SIGNATURE
DATE PHONE NUMBER
SECTION 4 – REQUIRED VENDOR AUTHORIZATION FOR ADD, CHANGE OR CANCELATION
I hereby authorize the Department of Administrative Services to deposit payments from the State of Iowa to the account designated on
this form and to initiate any adjustments or debit entries to this account for
any erroneous deposits in the amount of the error only. I also
understand that the State of Iowa can only deposit funds into one financial institution and account.
I certify that I am authorized to enter into this agreement as the account holder or on behalf of the account holder.
AUTHORIZED NAME TITLE DATE
SIGNATURE PHONE NUMBER
Mail or Fax Completed Form to: Dept. Admin Services-State Accounting Enterprise
Attn: EFT Coordinator
Fax Number Hoover State Office Building, 3
rd
FL Phone Number
(515) 281-5255 Des Moines, Iowa 50319 (515) 281-0246
Updated 07/2014
