LINN-BENTON HOUSING AUTHORITY
AUTHORIZATION AGREEMENT FOR DIRECT DEPOSIT
Use this form to add, change, or cancel Direct Deposit. Each action requires a separate form
and all changes must be in writing. You may select only one bank account for enrollment in
Direct Deposit. Please keep a copy for your records.
Please check the appropriate action:
______ Add new account only ______ Cancel account only
______ Cancel current account and add the following new account
Please check the appropriate account type and provide the following bank information
(select only one):
______ Checking Account ______ Savings Account
Bank Name: _____________________________________________________
Bank Routing/Transit Number: _____________________________________________
Bank Account Number: _______________________________________
I authorize Linn-Benton Housing Authority to initiate electronic credit entries to the bank account shown
above. This authority will remain in effect until I have cancelled it in writing or I no longer participate in the
Section 8 Housing Choice Voucher Program. By signing this form, I also agree that I will keep my contact
address updated with the Linn-Benton Housing Authority. If my contact address is not kept updated, then I
understand that my HAP disbursement will be withheld until the current contact address is received by
the Housing Authority.
Landlord Name (please print): ___________________________ Phone #: ______________
Landlord Signature: ___________________________________ Date: ___________________
E-mail Address(es): _____________________________________________________________
Housing Authority Landlord ID # (If known) : ___________
PLEASE ATTACH A VOIDED CHECK IF YOU DESIGNATE A CHECKING ACCOUNT OR A DEPOSIT SLIP
IF YOU DESIGNATE A SAVINGS ACCOUNT. YOUR ENROLLMENT IN DIRECT DEPOSIT CANNOT BE
PROCESSED WITHOUT THE APPROPRIATE VOIDED CHECK OR DEPOSIT SLIP.
PLEASE MAIL OR DELIVER THIS FORM TO: Or EMAIL: Jessica@L-bha.org
Linn-Benton Housing Authority Fax: (541)926-3589
Attn: Administrative Services Department
1250 Queen Ave. SE
Albany, OR 97322
***Enroll for payment statements at www.pal.hmsforweb.com.
If you have any questions regarding Direct Deposit, please call Leesa Scheele at 541-926-4497 ext. 250.
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