1/2006, dda_vendor06
Entered ________ ________
Initials Date
Verified ________ ________
Initials Date
Western Illinois University
Direct Deposit Authorization-Parent Borrower
(not for student use)
Check one
____ Direct Deposit for the first time ____ Direct Deposit change
Name of Payee
(last, first, middle initial) FEIN or SSN
Legal Address of Payee City State Zip
Name of contact person if other than payee Daytime Phone Number
Email Address (REQUIRED-remittance information will be sent)
Name of Financial Institution
Check One:
__ Checking Account __ Savings Account
Exact Name(s) on Account
Transit/Routing Number Depositor Account Number (enter the complete account number,
including the preceding & trailing zeroes)
I certify that the information provided on this form is correct. I authorize Western Illinois University to direct payments to the financial
institution designated above and to initiate, if necessary, debit entries and adjustments for any credit entries in error. This authorization is
applicable to all payments issued to the above-named payee by Western Illinois University under the designated FEIN or SSN.
Signature
Date
****Please attach a voided check or deposit slip here****
Please return this form to:
Western Illinois University
Accounts Payable
1 University Circle
Macomb IL 61455
Phone 309.298.1811
Fax 309.298.2811
PRIVACY ACT STATEMENT
The following information is provided to comply with the Privacy Act of 1974 (P.L. 93-579). All
information collected on this form is required under the provisions of 31 U.S.C. 3322 and 31 CFR
210. This information will be used to transmit payment data, by electronic means to vendor’s
financial institution. Failure to provide the requested information may delay or prevent the receipt of
payments through the Automated Clearing House Payment System.
