EFT
ELECTRONIC FUNDS
TRANSFER REQUEST
(EMPLOYER)
PLEASE PRINT OR TYPE
Information
Employer Name
Employer Account Number*
Address Town/City State Zip Code
Phone Email Address
Bank Information
Name of Bank Bank Telephone Number
Bank Routing Number* Bank Account Number*
Bank Address Town/City State Zip Code
Is the transaction type to be directly deposited into your account as per your instructions above?
Yes No
EFTE0 520
Please return this completed form to:
The Ministers and Missionaries Benefit Board
475 Riverside Drive, Suite 1700 New York, NY 10115-0049
Phone: 800.986.6222 Fax: 800.986.6782 Web: www.mmbb.org or you can email it to billing@mmbb.org.
EFT Authorization Agreement
Upon completion of this form, I hereby authorize The Ministers and Missionaries Benefit Board (MMBB) to deposit payments
electronically into my account or withdraw any funds from my account as instructed above. Further, I authorize MMBB to
initiate, if necessary, debit entries and adjustments for any credit entries made to my account in error. To ensure that my
account is properly credited or debited as instructed above, I have attached a voided check from my checking account where
my payments will be deposited or with
drawn. I
agree that this authorization will remain in effect until I provide notification
terminating this service.
Signature of Authorized Personnel* Date (mm/dd/yyyy)*
PLEASE
Staple or tape a blank voided check for checking account.
OR
If you are submitting this form electronically include a digital
photo or scan of the voided check.
*required fields
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