1 Doyon Place, Suite 300, Fairbanks, AK 99701 • Phone 907-459-2040 • Fax 907-459-2065 • E-mail records@doyon.com
1. Section 1: Applicant Information
a. Complete Section 1 thoroughly for yourself or ward applicant.
b. Must provide verifying information in order for your request to be processed.
c. E-mail address; by providing you will automatically receive an E-Newsletter.
d. Check boxes if you are needing an address update or if you wish to receive your Doyon
correspondence electronically.
2. Section 2: Ward Information: Child or Incapacitated Adult Ward
a. Only complete this section if you want your ward’s dividend deposited into the bank
account provided.
b. If applying for ward only, please enter their personal information in Section 1.
i. Add any additional wards in space provided.
c. If ward’s name is not on the account provided, the bank may reject the deposit.
d. Only the Custodian of record can complete and sign an application for a ward.
3. Section 3: Account Information and Authorization
a. Indicate Checking or Savings account and print bank name
b. Enter nine-digit routing number and account number. Call bank to obtain routing #.
c. Read authorization and sign application. We are unable to process applications without
a signature. Electronic signatures will not be accepted.
4. Account Verification:
a. Please ensure the account information provided is correct. If needed, contact your financial
b. Attach voided check or member verification from bank, if available.
c. If for some reason the bank returns the funds, a check will be mailed to address on file.
5. Canceling direct deposit:
a. In order to cancel direct deposit you must provide Doyon with a signed request.
b. If for any reason you should need to cancel your direct deposit, it must be done in
writing prior to the next distribution deadline.
6. Direct deposit:
a. May not be deposited into foreign bank accounts or prepaid bank cards.
b. May only take place on scheduled direct deposit dates.
c. Shareholders with distribution withholdings (IRS, child support) may not receive direct
d. May not take place for any held payments; i.e., bad address, inheritance, etc.
e. Must maintain a valid mailing address to receive direct deposit.
f. Return information on bottom.
g. If you fax in your application, please call the Records department to confirm fax was
h. Application may be completed on-line but must be printed to provide a physical signature.
Doyon, Limited
Direct Deposit Application
1 Doyon Place, Suite 300, Fairbanks, AK 99701 • Phone 907-459-2040 • Fax 907-459-2065 • E-mail records@doyon.com
First Name Middle Last Suffix
/ / /
Address Update
Last four digits of SSN Date of Birth
City State Zip Code
Mailing Address
Phone # Email
Bank Name: _____________________________________________
Direct Deposit
Routing Number: ____|____|____|____|____|____|____|____|____ Checking OR Savings
(Contact Bank if unknown)
Account Number: ___________________________________________________
I hereby authorize Doyon, Limited to initiate credit entries and to initiate, if necessary debit entries and adjustments for any
credit entries to my account. By signing below, I certify that I am the owner of this account. This authority is to remain in full
force and effect until Doyon has received written notice from me of its termination in such manner as to afford Doyon and my
bank a reasonable opportunity to act on it.
__________________________________ _________________________ ______________
Physical Signature Print Name Date
Shareholder ID ___________________________________ Hold Codes? N/Y If yes, list ________________
Entered by: ___________________Date: ___________ Verified by: ___________________Date:_________
Ward Name: Date of Birth:
For Office Use Only:
For checking, attach
voided check if available.
1. Applicant Information
Check box if you wish to receive your Annual Meeting materials
electronically; by providing you will also receive an E-Newsletter
Please Note: If any of the shareholders listed below are NOT on the account provided, the bank reserves the right to refuse the deposit. Only
complete this section if you wish for your ward’s dividend to be deposited into the account provided below.
2. Ward Information
3. Account Information and Authorization