Fillable Direct Deposit Authorization for Electronic Funds Transfer (EFT)

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Direct Deposit Authorization for Electronic Funds Transfer (EFT)

On average this form takes 8 minutes to complete

The Direct Deposit Authorization for Electronic Funds Transfer (EFT) form is 1 page long and contains:

  • 1 signature
  • 2 check-boxes
  • 27 other fields

Country of origin: OTHERS
File type: PDF

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Direct Deposit Authorization for
Electronic Funds Transfer (EFT)
Please upload this form to your RentHelpMN account at:
apply.renthelpmn.org
or mail to:
RentHelpMN
Document Services Center
1055 American Boulevard, Suite A
Bloomington, MN 55420
Fax: 952-285-2318
Instructions for completing this form are on the back.
Please print clearly and use black ink.
Mailing Address (General)
Name
Address
City
State
Zip Code
Contact Information - Please list person who can respond if additional information is required.
Contact Name
Email Address
Email address for payment notification
(if different from above)
Phone - - Ext
Tax Identification Information
Federal ID/Social Security Number
Federal ID/Social Security Name
Financial Institution Information
Note: Do not use /, \, *, - or ~ in any fields in this section.
Replace with spaces.
ABA Routing Number
Customer Account Number
Financial Institution
Street Address
City, State, ZIP Code
Type of Account: Checking Savings
Authorization to Make Electronic Fund Payments
Authorized Signature Printed Name Title Date
I authorize the Minnesota Housing Finance Agency, Dakota County, Hennepin County, Ramsey County, Washington County, and the
cities of Minneapolis and Saint Paul, and their successors and assigns, collectively referred to as RentHelpMN, to deposit, by electronic
fund transfer, payments owed to me by RentHelpMN and, if necessary, debit entries and adjustments for any amounts deposited
electronically in error. RentHelpMN shall deposit the payments in the financial institution and account designated above. I recognize that if
I fail to provide complete and accurate information on this authorization form, the processing of the form may be delayed or my payments
maybe erroneously transferred electronically.
I consent to and agree with the National Automated Clearing House Association Rules and Regulations and RentHelpMN's Ruleabout
electronic transfers as they exist on the date of my signature on this form or as subsequently adopted, amended or repealed.
click to sign
signature
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Completing the Direct Deposit Authorization for Electronic Fund Transfer (EFT) Form
Notice of Intent to Collect Private Data
All payment recipients are asked to provide private data to the Minnesota
Housing Finance Agency, Dakota County, Hennepin County, Ramsey County,
Washington County, the cities of Minneapolis and Saint Paul, and their
successors and assigns, hereafter referred to collectively as RenHelpMN, for
the following purposes.
State employees who support this function of the state’s accounting system
need to access the data to verify information. Others who have legal access to
the data include: Legislative Auditor, Attorney General, enforcement agencies
with statutory authority, and any other person or entity authorized by law or
court order.
Social Security Number (SSN) or Federal Employee Identification
Number (FEIN): Needed for identification purposes. This number is
used to match recipients with payments. This number is also called a
Tax Identification Number or TIN number. You are not legally required
to provide this data. However, without this information we cannot
convert you to EFT.
ABA Routing Number, Account Number, Account Type: This data is
required to correctly deposit payments to your designated bank
account. You are required by law to provide this information.
Incomplete information may cause a delay in converting to EFT.
Additionally, incorrect information may cause a payment to be delayed
or deposited to the wrong account.
Instructions for Completing the Form
Determine which bank accounts will be used for direct deposit. A
separate copy of the Electronic Fund Transfer Authorization form is
required for each bank account.
Mailing Address (General)
Name, Address, City, State, Zip Code. Enter the name of the
business or individual, address, city, state, and zip code.
Contact Information
Enter the name, email address, and phone number of the person
who can respond to questions regarding the information provided on
this form.
Tax Identification Information
Federal ID/ Social Security Number and Name. Enter the nine-digit
Federal Employer Identification Number (FEIN) for business, or the
nine-digit Social Security Number (SSN). Enter the name associated
with either the FEIN or SSN listed on the form.
Financial Institution Information
1.
ABA Routing Number. Enter the ABA Routing Number to identify
your financial institution. Contact your bank if you are not sure
what number to put in this field.
2.
Customer Account Number. Enter your bank account number.
Contact your bank if you are not sure what number to put in this
field.
3.
Financial Institution Name, Address, City, State, Zip Code. Enter the name
and address of your financial institution.
4.
Type of Account. Indicate if the account listed on this form is a
checking or savings account.
Authorization to Make Electronic Fund Payments
Sign the form and print your name and title (if any) and
the date.
Send the Form
Please upload this form to your RentHelpMN account at:
apply.renthelpmn.org
or mail to:
RentHelpMN
Document Services Center
1055 American Boulevard, Suite A
Bloomington, MN 55420
or
Fax: 952-285-2318
To change your ACH payment information complete a new ACH
form and upload to your RentHelpMN account, or mail or fax
the form using the information above.
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Direct Deposit Authorization for Electronic Funds Transfer (EFT)

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Completed 13 November 2021

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