Fillable Soboba Band of Luiseo Indians (Soboba Band of Luiseno Indians)

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Soboba Band of Luiseo Indians (Soboba Band of Luiseno Indians)

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Country of origin: US
File type: PDF

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A
pproved/Updated 2/17/16
Soboba Band of Luiseño Indians
P.O. Box 487, San Jacinto, CA 92581 * 951.654.2765
CANCEL DIRECT DEPOSIT
(CHANGES MUST BE SUBMITTED BY THE 15
TH
OF EACH MONTH)
IMPORTANT: Please read and sign before completing and submitting.
TRIBAL MEMBER INFORMATION
First
Middle
Last
SSN
Home Phone
Cell Phone
BANK NAME
BANK NAME
Please check () one:
Checking
Savings
Account Number: ____________________________
Routing Number: ____________________________
Please check () one:
Checking
Savings
Account Number: ____________________________
Routing Number: ____________________________
I wish to cancel my enrollment for Direct Deposit.
I hereby authorize my employer, (hereinafter “Company”) to cancel my Direct Deposit to my account(s) at the financial
institution(s) (hereinafter “Bank”) indicated on this form.
This authorization is to remain in full force and effect until Company and Bank have received written notice from me of
re-enrollment.
_________________________________________
Signature
_________________________________________
Date
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Soboba Band of Luiseo Indians (Soboba Band of Luiseno Indians)

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Completed 20 July 2020

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