DC: 1401 Columbia Rd NW, Washington, DC 20009 | (202) 588-5102
MD: 11002 Veirs Mill Road, Suite 503, Wheaton, MD 20902 | 1-866-977-LEDC
3500 Boston Street, Suite 431, Baltimore MD 21224 | (443) 708-7035
10 E North Avenue, Baltimore, MD 21202 | (443) 708-7035
VA: 2300 9th Street South, Suite 300 B, Arlington, VA 22204 | (703) 527-3854
PR: 828 Ave. Hostos, Edificio Villa Capitán II, Suite 204, Mayaguez, PR 00682 | (787) 510-5332
PAYMENT INFORMATION FORM
Business/ Individual Name
Preferred Mailing Address
Email Address for Contact Person
Phone Number for Contact Person
If requesting a check as form of payment proceed to signature section. (Please allow an additional 3-5 days if
If choosing electronic payment, please provide the following information for the depository account named below.
Bank Financial Institution Name
Business/Individual Bank Account Name
Bank Routing/ABA # (ACH) – (9 Digits)
Business/Individual Bank Account Number
Please indicate the type of account (Checking or
I hereby authorize Latino Economic Development Center (LEDC) to deposit any specific payment to my business or individual account with the bank
named above. This authorization is to remain in full force and effect until LEDC has received written notification from me of its termination in such
time and in such manner as to afford LEDC and/or the Bank a reasonable opportunity to act on it.
If funds to which I am not entitled to are deposited to my account, I (we) authorize the LEDC to direct the financial institution to return said funds.
TERMS AND CONDITIONS OF THE FOREGOING COMMITMENT ARE UNDERSTOOD AND ACCEPTED
BY THE UNDERSIGNED.
Latino Economic Development Center
Executive Director and CEO, Latino Economic Development Corporation of Washington D.C.
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