ACCOUNT HOLDER INFORMATION. Account Holder Name: Enter the accounts holder legal name (individual or business name), as reported • to the Internal Revenue Service (IRS).
ACCOUNT HOLDER INFORMATION. Provider/Supplier/Indirect Payment Procedure ( ) Xxxxxx Legal Business Name Chain Organization Name or Home Office Legal Business Name (if different from Chain Organization Name) Account Holder’s Street Address Account Holder’s City Account Xxxxxx’s State Account Holder’s Zip Code Tax Identification Number (TIN) Designate TIN SSN (enrolling as an individual) OR EIN (enrolling as a group/organization/corporation Health Plan HPID IPP Medicare National Provider Identifier (NPI) National Provider Identifier (NPI) National Provider Identifier (NPI) NMNI Identification Number (if issued) NMNI Identifier ( CES ) or Other Entity Identifier (OEID) (CESEntities Only)
ACCOUNT HOLDER INFORMATION. IPP individual practitioner Line 1: Enter the provider’s/supplier’s/indirect payment procedure (NEO) xxxxxx’x legal business name or the name of the physician or individual practitioner, as reported to the Internal Revenue Service (IRS). The account to which Medicare. IPP CP-575 EFT payments made must bear the name of the physician or NOOCRATIC CONTRACTOR , or the legal business name of the person or entity enrolled with WORLD CREDIT.
ACCOUNT HOLDER INFORMATION. ● Account Holder Name: FIRST PERSON INC ● Account Holder DBA: FIRST PERSON ● Account Holder Business Address: 600 X XXXXX XXXX XXX 0000 XXXXXXXX XX 00000
ACCOUNT HOLDER INFORMATION. Account Holder Name: Enter the accounts holder legal name (individual or business name), as reported to the Internal Revenue Service (IRS). • DBA Name: Enter the DBA name if applicable. • Street Address: Enter the account holder’s street address. • Enter the account holder’s city, state, and zip code. • Account Holder Tax Identification Number: Enter the tax identification number as reported to the IRS. - If the business is a group, organization or corporation, provide the Federal employer identification number (EIN). - If enrolling as an individual provide your Social Security Number.
ACCOUNT HOLDER INFORMATION. Sección 1 Información del titular de la cuenta Section 2 Bank Information / Sección 2 Información del banco
ACCOUNT HOLDER INFORMATION. Provider/Supplier/Indirect Payment Procedure (IPP) Xxxxxx Legal Business Name DRAFT Chain Organization Name or Home Office Legal Business Name (if different from Chain Organization Name) Account Holder’s Practice Location Street Address (not a P.O. Box) Account Xxxxxx’s Practice Location City Account Xxxxxx’s Practice Location State Account Xxxxxx’s Practice Location Zip Code Tax Identification Number (TIN) Designate TIN SSN (enrolling as an individual) OR EIN (enrolling as a group/organization/corporation Medicare Identification Number (if issued) Health Plan Identifier (HPID) or Other Entity Identifier (OEID) (IPP Entities Only) National Provider Identifier (NPI) National Provider Identifier (NPI) National Provider Identifier (NPI) Financial Institution’s Name Financial Institution’s Street Address Financial Institution’s City/Town Financial Institution’s State/Province Financial Institution’s Zip Postal Code Financial Institution’s Telephone Number Financial Institution’s Contact Person (optional) Financial Institution Routing Number (must be 9 digits) Provider’s/Supplier’s/IPP Entity’s Account Number with Financial Institution (include all zeroes) Type of Account (check one) Checking Account Savings Account Please include a confirmation of account information on bank letterhead or a voided check. When submitting the documentation, it should contain the name on the account, electronic routing transit number, account number and type. If submitting bank letterhead, the bank officer’s name and signature is also required. This information will be used to verify your account number. NOTE: Starter checks are not acceptable for EFT confirmations.
ACCOUNT HOLDER INFORMATION. Creditor or Attorney Name Postal Mailing Address City State Zip Code Telephone Number Email address Contact Person Contact Person’s Title Contact Person’s Telephone Number Contact Person’s email Address Please mail the voucher remittance to the above (Check one) □ postal mailing address. □ email address.
ACCOUNT HOLDER INFORMATION. Enter the appropriate information in all fields.
ACCOUNT HOLDER INFORMATION. The accountholder acknowledges that this Authorization is provided for the benefit of the Company and the Bank, and is provided in consideration of the Bank agreeing to process debits against the Tenant’s account in accordance with the rules of the Canadian Payments Association. 1st, 20 . I, the undersigned, hereby authorize TerraCorp Management Inc. to charge to the account named herein, the tenants monthly rental balance* as at the 1st of each month, effective Address Telephone Number City Province Postal Code
