AUTHORIZATION AGREEMENT FOR ELECTRONIC FUNDS TRANSFER (EFT)Authorization Agreement for Electronic Funds Transfer (Eft) • January 19th, 2017
Please indicate the tax types that you will be paying by EFT by checking the appropriate tax type box(es) below. Indicate also if you are required to pay those taxes by EFT (i.e., your annual tax liability exceeds $100,000, or your annual withholding exceeds $40,000). Note: The Department will not require an employer whose withholding liability exceeds $40,000 to pay by EFT if such employer is not required to remit their federal employment taxes electronically.
AUTHORIZATION AGREEMENT FOR ELECTRONIC FUNDS TRANSFER (EFT)Authorization Agreement for Electronic Funds Transfer (Eft) • June 8th, 2012
Authorization Agreement for Electronic Funds Transfer (EFT)Authorization Agreement for Electronic Funds Transfer (Eft) • February 15th, 2021
Authorization Agreement -Authorization Agreement for Electronic Funds Transfer (Eft) • February 27th, 2013
AUTHORIZATION AGREEMENT FOR ELECTRONIC FUNDS TRANSFER (EFT)Authorization Agreement for Electronic Funds Transfer (Eft) • December 7th, 2020
VENDOR INFORMATION 1. VENDOR LEGAL BUSINESS NAME (must match name on financial institution account and name registered with Alliance Health, if applicable) 2. ACCOUNT HOLDER’S NAME 3. CONTACT TELEPHONE NUMBER 4. VENDOR ADDRESS CITY STATE ZIP 5. VENDOR COMPLETE FEDERAL TAX ID NUMBER (must match number registered with Alliance Health, if applicable) 6. EMAIL ADDRESS – for Electronic Remittance Forms to be Sent
AUTHORIZATION AGREEMENT FOR ELECTRONIC FUNDS TRANSFER (EFT)Authorization Agreement for Electronic Funds Transfer (Eft) • October 22nd, 2003
Please include a voided check, preprinted deposit slip, or confirmation of account information on bank letterhead with this agreement for verification of your account number.
Iowa Authorization Agreement for Electronic Funds Transfer (EFT)Authorization Agreement for Electronic Funds Transfer (Eft) • October 14th, 2011
This form authorizes the Iowa Department of Revenue to process variable EFT entries to your account, but only by your initiation.
AUTHORIZATION AGREEMENT FOR ELECTRONIC FUNDS TRANSFER (EFT)Authorization Agreement for Electronic Funds Transfer (Eft) • December 15th, 2016
Authorization Agreement for Electronic Funds Transfer (EFT)Authorization Agreement for Electronic Funds Transfer (Eft) • July 15th, 2013
ContractAuthorization Agreement for Electronic Funds Transfer (Eft) • January 22nd, 2014
AUTHORIZATION AGREEMENT FOR ELECTRONIC FUNDS TRANSFER (EFT)Authorization Agreement for Electronic Funds Transfer (Eft) • May 20th, 2019
AUTHORIZATION AGREEMENT FOR ELECTRONIC FUNDS TRANSFER (EFT)Authorization Agreement for Electronic Funds Transfer (Eft) • February 10th, 2023
Tammy L. Terry, Chapter 13 Standing Trustee, hereafter called Trustee, is hereby authorized to initiate credit and debit entries (creditor will be notified prior to debit entries) to the account indicated below. This authority is to remain in full force and effect until Trustee has received WRITTEN notification from me or other authorized representative for me of the termination in such time and such manner as to afford Trustee a reasonable opportunity to act on it. This authorization will terminate if Trustee discontinues the Electronic Creditor Disbursement Program.
AUTHORIZATION AGREEMENT FOR ELECTRONIC FUNDS TRANSFER (EFT)Authorization Agreement for Electronic Funds Transfer (Eft) • December 1st, 2006
AUTHORIZATION AGREEMENT FOR ELECTRONIC FUNDS TRANSFER (EFT)Authorization Agreement for Electronic Funds Transfer (Eft) • June 19th, 2012
AUTHORIZATION AGREEMENT FOR ELECTRONIC FUNDS TRANSFER (EFT) AUTOMATIC DEPOSITS/PAYMENTSAuthorization Agreement for Electronic Funds Transfer (Eft) • February 10th, 2014
AUTHORIZATION AGREEMENT FOR ELECTRONIC FUNDS TRANSFER (EFT)Authorization Agreement for Electronic Funds Transfer (Eft) • May 27th, 2009
Authorization Agreement for Electronic Funds Transfer (EFT)Authorization Agreement for Electronic Funds Transfer (Eft) • June 21st, 2019
This authorization will remain in effect until your bank has received written notification from PEBA to stop the deduction.
AUTHORIZATION AGREEMENT FOR ELECTRONIC FUNDS TRANSFER (EFT)Authorization Agreement for Electronic Funds Transfer (Eft) • August 7th, 2013
This authorization is effective as of the signature date below and is to remain in full force and effect until Alliance Health has received written notification of its termination in such time and such manner as to afford Alliance Health and the financial institution a reasonable opportunity to act on it, or until Alliance Health deems it necessary to terminate this agreement. Under penalties of perjury, I hereby certify the checking OR savings account indicated on this form are under my direct control and access; therefore, I authorize Alliance Health to initiate, change, or cancel credit entries to the financial institution account as indicated above. If my financial institution information changes, I agree to submit to Alliance Health a revised Authorization Agreement for Electronic Funds Transfer form.
AUTHORIZATION AGREEMENTAuthorization Agreement for Electronic Funds Transfer (Eft) • December 19th, 2005
AUTHORIZATION AGREEMENT FOR ELECTRONIC FUNDS TRANSFER (EFT)Authorization Agreement for Electronic Funds Transfer (Eft) • April 20th, 2016
The State Board of Equalization is hereby authorized to initiate debit entries to the bank account identified below and the bank is authorized to debit such account. This authority is to remain in full force until EFT payments are no longer required by statute or, if I am a voluntary participant, until the State Board of Equalization and I mutually agree to terminate my participation in the EFT program.
AUTHORIZATION AGREEMENT FOR ELECTRONIC FUNDS TRANSFER (EFT)Authorization Agreement for Electronic Funds Transfer (Eft) • October 3rd, 2003
Authorization Agreement for Electronic Funds Transfer (EFT) of LWC Unemployment Tax PaymentsAuthorization Agreement for Electronic Funds Transfer (Eft) • December 16th, 2004
Employer Name or Authorized Agent *State ID#. Federal ID#. 1ST Contact Person Telephone 2nd Contact Person Telephone Mailing Address for EFT purposes (Street Address, Box number) Signature Title Date
AUTHORIZATION AGREEMENT FOR ELECTRONIC FUNDS TRANSFER (EFT)Authorization Agreement for Electronic Funds Transfer (Eft) • October 22nd, 2003
Depository Name Account Holder’s Name Street Address City State Zip Code Depository Telephone Number Depository Contact Person Depository Routing Transit Number (nine digit)
Authorization Agreement for Electronic Funds Transfer (EFT)Authorization Agreement for Electronic Funds Transfer (Eft) • October 16th, 2009
Print or type.Please fill in all portions as applicable. Incomplete agreements cannot beprocessed. Company Name (if applicable): Name (Last, First, Middle Initial) {Only for payment of individuals}: Last Name First Name Middle Initial Mailing Address: Number, street, and apt. or suiteno. City, state, and zip code
Authorization Agreement for Electronic Funds Transfer (EFT)Authorization Agreement for Electronic Funds Transfer (Eft) • August 13th, 2020
Authorization Agreement for Electronic Funds Transfer (EFT) of LWC Unemployment Tax PaymentsAuthorization Agreement for Electronic Funds Transfer (Eft) • December 16th, 2004
Employer Name or Authorized Agent *State ID#. Federal ID#. 1ST Contact Person Telephone 2nd Contact Person Telephone Mailing Address for EFT purposes (Street Address, Box number) Signature Title Date
Authorization Agreement for Electronic Funds Transfer (EFT)Authorization Agreement for Electronic Funds Transfer (Eft) • March 14th, 2018
Effective Date of Change: Named Insured: Account Number: Bank Information Name and Address of Bank: Type of Account: (Checking or Savings) Bank Account Number: Routing Number: (9 digit number between the two colons on the bottom of your check) Name as it appears on your bank account: Payment Plan: (Full Pay, 4 Pay, 9 Pay, 12 Pay) The day of the month you wish to have funds withdrawn: (1st through 28th) _ Terms of Agreement I hereby request and authorize MMG Insurance to debit/credit my bank account as payments for my policies become due. I agree that if a debit/credit is dishonored, the bank shall have no liability if the dishonored debit/credit results in the forfeiture of insurance. This authorization is to remain in full force until MMG Insurance and the above named bank have written notice from me of its termination. No payment to MMG Insurance shall be deemed to have been made unless and until MMG Insurance receives actual credit. Signature of Bank Account Holder: Date
Authorization Agreement for Electronic Funds Transfer (EFT)Authorization Agreement for Electronic Funds Transfer (Eft) • June 2nd, 2021
This form must be submitted through the ProviderOne Portal. Only social services and medical providers need to submit changes through ProviderOne. Please read completely before filling out your EFT authorization form. Failure to fill out your Authorization Agreement for EFT entirely with accurate information could result in update delays.
AUTHORIZATION AGREEMENT FOR ELECTRONIC FUNDS TRANSFER (EFT)Authorization Agreement for Electronic Funds Transfer (Eft) • July 24th, 2019
AUTHORIZATION AGREEMENT FOR ELECTRONIC FUNDS TRANSFER (EFT)Authorization Agreement for Electronic Funds Transfer (Eft) • September 9th, 2021
This agreement is to remain in full force and effect until JMT and BANK receive written notification of termination from COMPANY, and in no event termination be effective with respect to debit entries originated prior to JMT’s receipt of notice of termination. This agreement shall be governed by the NACHA operation rules as in effect from time to time. The COMPANY understands that debit entries will be honored if sufficient funds are available in the COMPANY’s account. In the event a debit entry is returned to JMT uncollected, the gross amount of the invoiced or invoices covered by it will be immediately due and payable along with any associated finance and bank charges, and further participation in the plan, at the option of JMT, may be terminated. Future purchases, if the plan is terminated, will then be on terms as approved by JMT.
AUTHORIZATION AGREEMENT FOR ELECTRONIC FUNDS TRANSFER (EFT)Authorization Agreement for Electronic Funds Transfer (Eft) • March 21st, 2018
Tammy L. Terry, Chapter 13 Standing Trustee, hereafter called Trustee, is hereby authorized to initiate credit and debit entries (creditor will be notified prior to debit entries) to the account indicated below. This authority is to remain in full force and effect until Trustee has received WRITTEN notification from me or other authorized representative for me of the termination in such time and such manner as to afford Trustee a reasonable opportunity to act on it. This authorization will terminate if Trustee discontinues the Electronic Creditor Disbursement Program.
AUTHORIZATION AGREEMENT FOR ELECTRONIC FUNDS TRANSFER (EFT)Authorization Agreement for Electronic Funds Transfer (Eft) • July 28th, 2003
Authorization Agreement for Electronic Funds Transfer (EFT)Authorization Agreement for Electronic Funds Transfer (Eft) • April 18th, 2022
AUTHORIZATION AGREEMENT FOR ELECTRONIC FUNDS TRANSFER (EFT)Authorization Agreement for Electronic Funds Transfer (Eft) • June 2nd, 2009
AUTHORIZATION AGREEMENT FOR ELECTRONIC FUNDS TRANSFER (EFT)Authorization Agreement for Electronic Funds Transfer (Eft) • July 28th, 2003
