Fillable Email completed form to assetmanagement@nhhfa.org (New Hampshire Housing)

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Email completed form to assetmanagement@nhhfa.org (New Hampshire Housing)

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File type: PDF

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FOR NHHFA USE ONLY
PAYEE ID:
EFT ID:
ELECTRONIC FUND TRANSFER/PAYMENT
ENROLLMENT FORM
This form is used for establishing Automated Clearing House (ACH) payments with New Hampshire Housing.
PRIVACY ACT STATEMENT
The following information is provided to comply with the Privacy Act of 1974 (P.L. 93-579).
PAYER/COMPANY INFORMATION
NAME:
New Hampshire Housing Finance Authority
ADDRESS:
P.O. Box 5087
Manchester, NH 03108
CONTACT PERSON NAME:
TELEPHONE NUMBER:
ADDITIONAL INFORMATION: NEW / EXISTING
NAME/COMPANY INFORMATION
NAME: SSN NO. OR TAXPAYER ID NO.
ADDRESS:
CONTACT PERSON NAME: (if different from above)
DATE:
TELEPHONE NUMBER: E-MAIL ADDRESS:
SIGNATURE:
TITLE OF AUTHORIZED OFFICIAL: (for businesses only)
In signing this form, I authorize all payments to be sent to the bank/financial institution named below for
deposit to the designated account.
BANK/FINANCIAL INSTITUTION INFORMATION
NAME:
ADDRESS:
BANK/FINANCIAL INSTITUTION REPRESENTATIVE NAME: (if available)
TELEPHONE NUMBER:
NINE-DIGIT ROUTING TRANSIT NUMBER:
BANK/FINANCIAL INSTITUTION ACCOUNT NAME:
BANK/FINANCIAL INSTITUTION ACCOUNT NUMBER: TYPE OF ACCOUNT:
[ ] CHECKING [ ] SAVINGS
Email completed form to assetmanagement@nhhfa.org
MANAGEMENT & DEVELOPMENT
(603) 472-8623 Ext: 9263
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Email completed form to assetmanagement@nhhfa.org (New Hampshire Housing)

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Completed 30 August 2020

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