Fillable Form 199: Vermont Emergency Rental Assistance Program PO

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Form 199: Vermont Emergency Rental Assistance Program PO

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The Form 199: Vermont Emergency Rental Assistance Program PO form is 1 page long and contains:

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  • 10 check-boxes
  • 20 other fields

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File type: PDF

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Direct Deposit Authorization
PART 1: Transaction Ty
pe
PART 2: Payee Identification
___ I would like to receive correspondence via e
-
mail.
PART 3: Authorization for Setup, Changes, or Cancellation
PART 4: Financial Institution
(Contact your financial institution for this information, if necessary.)
New Setup
Change financial institution
Cancellation (Leave Part 4 Blank)
Change account number
Other
Change account type
Tax ID (Social Security Number or Employer Identification Number)
Work Phone Number
Home Phone Number
Name
E
-
mail Address
Address
City
State Zip Code
I hereby request and authorize the Vermont State Housing Authority to deposit payments by electronic funds transfer into the account
specified below and, if necessary, debit entries and adjustments for any amounts deposited electronically in error. I recognize that, if I fail
to provide complete and accurate information on this authorization form, the processing of the form may be delayed or that my
payments may be erroneously transferred electronically.
This authorization will remain in effect until written notice to terminate is given. The undersigned must allow a reasonable amount of
time for initiating or terminating Direct Deposit and is responsible for notification of any change in financial institution information.
Authorized Signature
Printed Name
Financial Institution Name
City
State
Zip Code
Type of Account
___ Consumer Checking
___Consumer Savings
___Corporate Checking
___Corporate Savings
Routing Transit Number:
Customer Account Number:
Vermont Emergency
Rental Assistance Program
PO
Box
199
M
anchester,
VT 05254-0998
833-4VT-ERAP (833-488-3727)
Please login to the VERAP landlord portal at: https://verapownerportal.reframeassist.io/#/auth/login and upload this
completed document.
Please make sure all information is correct before sending to VERAP. Incorrect
information may result in a delay or non-payment of VERAP assistance. Including a
voided check with this form is highly recommended to ensure accuracy.
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Form 199: Vermont Emergency Rental Assistance Program PO

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Completed 28 March 2022

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