City of Kannapolis, North Carolina
Authorization of Electronic Funds Transfer
Please Check One: Initial Enrollment Change
SOCIAL SECURITY #
or FEDERAL ID #: ______________________________________________________________________
If you should have any questions, please contact Finance Department at (704) 920-4380 or firstname.lastname@example.org
y signing below, I hereby authorize the City of Kannapolis to electronically deposit funds into the account checked below. I
understand that if my banking information changes and the City is not made aware of this change, then payment could be delayed.
acknowledge that electronic payments to the designated account must comply with the provisions of the U.S. law, as well as the
requirements of the Office of Foreign Assets Control (OFAC). Check one of the following:
affirm that, regarding electronic payments the City of Kannapolis may remit to the financial institution for credit to the
account that I have designated, the entire payment amount is not subject to being transferred to a foreign bank account.
I affirm that, regarding electronic payments the City of Kannapolis may remit to the financial institution for credit to the
account that I have designated, the entire payment amount is subject to being transferred to a foreign bank account. I
acknowledge that any electronic payments that may be remitted to me may be labeled with “IAT” as the standard entry class.
I acknowledge that the City of Kannapolis alternatively may elect to remit such payments to me via check instead of via
electronic payment. I acknowledge that availability of funds credited to the account will be subject to my receiving financial
institution’s policies and procedures.
CHECKING ACCOUNT: SAVINGS ACCOUNT:
PLEASE ATTACH A VOIDED CHECK IN THE SPACE PROVIDED.
lease mail form to: City of Kannapolis Finance Department
Attn: Accounts Payable- EFT
401 Laureate Way
Kannapolis, NC 28081
Or Fax to: (704) 938-5919
Or email to: email@example.com
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