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LAKE COUNTY EMERGENCY RENTAL ASSISTANCE PROGRAM LANDLORD -

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LAKE COUNTY
EMERGENCY RENTAL ASSISTANCE PROGRAM
LANDLORD - ACH FORM
Geminus C
orporation (Geminus) electronically processes payments for the Lake
County Emergency Rental Assistance (LCERA) if requested. Please provide the
following information so that Geminus may initiate direct deposits to your checking
or savings account:
Date:
Landlord Name:
Contact Name and Phone #:
Bank Name:
ABA Number:
Account Number:
Type of Account:
(checking or savings)
Print Name & Title:
Signature:
*
Ack
nowledgement: By typing your name below, you acknowledge and agree that this represents your
signature and you are attesting to all information being provided on this form.
Ch
eck here if you would like to opt out of receiving direct deposit and instead receive payment by
paper check. If checked, please complete information below. NOTE: By opting to receive a paper
check, you are acknowledging that payment will be delayed.
Payable to:
Add
ress:
City:
State:
Zipcode:
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LAKE COUNTY EMERGENCY RENTAL ASSISTANCE PROGRAM LANDLORD -

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Completed 25 May 2021

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