STATE ZIP
STATE
TYPE OF ACCOUNT Checking Other:
Authorized Signature: Date:
Title:
NAME OF FINANCIAL INSTITUTION
BANK ROUTING NUMBER BANK ACCOUNT NUMBER
Email address:
PHONE NUMBER
CITY
FAX NUMBER
FINANCIAL INSTITUTION INFORMATION
VENDOR NAME (as shown on your bank account)
BUSINESS NAME (if different from above)
CITY
ELECTRONIC FUNDS TRANSFER
REQUEST FORM
Do you want to receive your payment from Lake Havasu City faster? To register
with us to be paid via EFT (Electronic Funds Transfer) please complete the
information below and mail original to 2330 McCulloch Blvd. N., Lake Havasu City,
AZ 86403 - Attn: Accounts Payable.
ADDRESS
CONTACT NAME
I authorize Lake Havasu City to initiate accounting transactions to deposit funds directly to the account indicated
above and to correct any errors which may occur from these transactions. I also authorize the Financial Institution to
post these transactions to this account. This authorization is to remain in force until Lake Havasu City receives
written notice to cancel or change this authorization. Please allow 10 business days for our office to process any
change request.
Input By/Date: __________ Vendor #:__________
FOR LAKE HAVASU USE ONLY
FIN-10 EFT Form Rev 10-17-13
click to sign
signature
click to edit
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