Direct Deposit Request
Monthly Per Capita | Monthly Senior & Disability Payments
AUTHORIZATION AGREEMENT FOR DIRECT DEPOSITS (ACH CREDITS)
Account must be in member’s name including minors
Tribal ID #:
Routing #: Account #:
Per Capita Elder Support
I (we) hereby authorize , hereafter called COMPANY, to initiate
credit entries to my (our)
at the depository nancial institution named below, hereinafter called DEPOSITORY, and to credit the same to
such account. I (we) acknowledge that the origination of ACH transactions to my (our) account must comply with
the provisions of U.S. law.
This authorization is to remain in full force and effect until COMPANY has received written notication from me
(or either of us) of its termination in such time and in such manner as to afford COMPANY and DEPOSITORY a
reasonable opportunity to act on it.
NOTE: WRITTEN CREDIT AUTHORIZATION MUST PROVIDE THAT THE RECEIVER MAY REVOKE THE AUTHORIZATION
ONLY BY NOTIFYING THE ORIGINATOR IN THE MANNER SPECIFIED IN THE AUTHORIZATION.
This form MUST include a voided check or bank verication with tribal member’s name or processing will be delayed.
NO POWER OF ATTORNEY WILL BE ACCEPTED.
Form must be received within two weeks prior to any check distribution.
Phone: 360-716-4364 | Email: email@example.com | Fax: 360-716-0304
ATTACH VOIDED CHECK HERE
(with member’s name)
ATTACH INFORMATION PRINT OUT FROM