Electronic Funds Transfer (EFT) Authorization AgreementElectronic Funds Transfer Authorization Agreement • May 5th, 2020
By completing and submitting this form to the Missouri Medicaid Audit and Compliance Unit (MMAC) for processing, I understand• payment will be from Federal and State funds and that any falsification or concealment of material fact may be prosecuted under Federal and State laws;• the State of Missouri will initiate credit entries (deposits) and will initiate, if necessary, debit entries (withdrawals) or adjustments for any credit entries made in error to my account;• the State of Missouri may terminate my enrollment in direct deposit if the State is legally obligated to withhold part or all payments for any reason;• MMAC may terminate my enrollment if I no longer meet the eligibility requirements; and• this document does not constitute an amendment or assignment of any nature whatsoever of any contract, purchase order or obligation that I may have with any agency of the State of Missouri. SECTION I: PROVIDER INFORMATION PROVIDER NAME* DOING BUSINESS AS NAME (DBA) SECTION II: PROVIDER
ELECTRONIC FUNDS TRANSFER AUTHORIZATION AGREEMENTElectronic Funds Transfer Authorization Agreement • November 18th, 1999
AUTHORIZATION AGREEMENTElectronic Funds Transfer Authorization Agreement • May 18th, 2018
Company Name: CHAMPION SQUARE GARAGE I hereby authorize CHAMPION SQUARE GARAGE to initiate DEBIT entries and to initiate, if necessary, CREDIT entries and adjustments for any DEBIT entries in error to my (select one)🞏 checking or 🞏 savings account at the depository financial institution named below, hereinafter called DEPOSITORY, and to credit the same to such account. I acknowledge that the origination of ACH transactions from my account must comply with the provisions of U. S. law. Depository Financial Institution Name: CardNo. Branch: City: State: Zip: Routing #: Account #: Dollar Amount IMPORTANT: Attach a VOIDED check(voided deposit slip for savings account) for the above referenced account to this form. This authorization is to remain in full force and effect until CHAMPION SQUARE GARAGE has received written notification from me of its termination by the twentieth of the month for the next month’s payment. Customer Name Street Address (Plea
AUTHORIZATION AGREEMENTElectronic Funds Transfer Authorization Agreement • May 18th, 2018
Company Name: MERCEDES-BENZ SUPERDOME GARAGE I hereby authorize MERCEDES-BENZ SUPERDOME GARAGE to initiate DEBIT entries and to initiate, if necessary, CREDIT entries and adjustments for any DEBIT entries in error to my (select one)🞏 checking or 🞏 savings account at the depository financial institution named below, hereinafter called DEPOSITORY, and to credit the same to such account. I acknowledge that the origination of ACH transactions from my account must comply with the provisions of U. S. law. Depository Financial Institution Name: CardNo. Branch: City: State: Zip: Routing #: Account #: Dollar Amount IMPORTANT: Attach a VOIDED check(voided deposit slip for savings account) for the above referenced account to this form. This authorization is to remain in full force and effect until MERCEDES-BENZ SUPERDOME GARAGE has received written notification from me of its termination by the twentieth of the month for the next month’s payment. Customer Name
ELECTRONIC FUNDS TRANSFER AUTHORIZATION AGREEMENTElectronic Funds Transfer Authorization Agreement • April 15th, 2021
CAPS Electronic Funds Transfer Authorization AgreementElectronic Funds Transfer Authorization Agreement • September 28th, 2012
AUTOMATIC PAYMENTS – ELECTRONIC FUNDS TRANSFER AUTHORIZATION AGREEMENTElectronic Funds Transfer Authorization Agreement • August 26th, 2013
Authorization Agreement – Instructions and Enrollment FormElectronic Funds Transfer Authorization Agreement • January 29th, 2020
Electronic Funds Transfer (EFT) allows Delta Dental member companies and their affiliates to send payment directly to your bank account. Explanations of Benefits will no longer be sent to you via the United States Postal Service, now offering a one stop solution for your Delta Dental patient’s EOBs using our National Portal. EFT is applicable to all providers at the Business (Tax Identification Number)/ Service Office indicated on your application unless otherwise noted. Please note that changes in your Tax Identification Number or Service Office address will terminate your EFT for that office; please complete a new EFT Authorization Agreement when modifying business information. General Instructions EFT Enrollment is applied to all providers at the specified business service office. You can add one or more business service offices for the Tax Identification Number or Employee Identification Number entered. A copy of a voided check or a bank letter must be forwarded to the address, ema
Authorization Agreement for Automatic Transfers from Church Member Account to the Church Account (Ach Debits)Electronic Funds Transfer Authorization Agreement • November 5th, 2019
This authorization is to remain in full force and effect until Church has received written notification from me (or either of us) of its termination in such a time and such manner as to afford Church and the Financial Institution a reasonable opportunity to act on it.
Connecticut Medical Assistance Program Electronic Funds Transfer (EFT) Authorization AgreementElectronic Funds Transfer Authorization Agreement • April 28th, 2017
The Department of Social Services (DSS) requires providers to participate in electronic funds transfer (EFT). Electronic Funds Transfer (EFT) provides for the direct deposit of your payment amount into a bank account of your choosing and is available to Connecticut Medical Assistance Program providers. EFT is a more efficient and cost effective means of reimbursement for Connecticut Medical Assistance Program services.
ELECTRONIC FUNDS TRANSFER (EFT or ACH) AUTHORIZATION AGREEMENTElectronic Funds Transfer Authorization Agreement • September 30th, 2020
This authorization is to remain in full force and effect until I have received notification of its termination in such time and in such manner as to afford the Conference and Financial Institution a reasonable opportunity to act on it.
ELECTRONIC FUNDS TRANSFER AUTHORIZATION AGREEMENTElectronic Funds Transfer Authorization Agreement • October 22nd, 2007
VENDOR NAME (COMPANY NAME) VENDOR NUMBER (TO BE COMPLETED BY SCOTT & WHITE) ADDRESS CITY STATE ZIP ACCOUNTING/EFT CONTACT NAME TELEPHONE NUMBER FAX NUMBER IRS TAXPAYER ID (FEIN) EMAIL ADDRESS FOR REMITTANCEADVICE* (One email address only) FAX NUMBER FOR REMITTANCE ADVICE *
Electronic Funds Transfer Authorization Agreement for ACH Credit Payment MethodElectronic Funds Transfer Authorization Agreement • February 20th, 2007
I/we hereby agree to comply with the Department’s requirements for the ACH Credit Payment method. I/we also authorize the Department to update our payment method to ACH Debit if I/we repeatedly fail to correctly complete the payment transactions in accordance with the required procedures set forth by the Department.
Authorization Agreement for Automatic Debits of DonationsElectronic Funds Transfer Authorization Agreement • September 28th, 2021
I/We authorize Christian Missions In Many Lands, Inc. (CMML) to initiate a monthly debit entry in the amount(s) listed below, from the account at the financial institution named below, and authorize the institution to debit the below named account for the same.
ALLMERICA FINANCIAL CITIZENS INSURANCE HANOVER INSURANCE ®Electronic Funds Transfer Authorization Agreement • August 27th, 2003
AUTOMATIC PAYMENTS – ELECTRONIC FUNDS TRANSFER AUTHORIZATION AGREEMENTElectronic Funds Transfer Authorization Agreement • February 21st, 2012
ELECTRONIC FUNDS TRANSFER (EFT) AUTHORIZATION AGREEMENTElectronic Funds Transfer Authorization Agreement • April 30th, 2009
As the Named Insured, I (we) hereby authorize Anchor General Insurance Agency, Inc.(Anchor), its subsidiaries and affiliates, to electronically deduct monthly installments for payment of my (our) insurance policy premiums, subsequent renewal down payment and monthly installments, and to initiate credit entries in the event of erroneous charges. I (we) hereby authorize the Financial Institution indicated below to accept and post these transactions to my (our) checking account. I (we) agree that Anchor will not be responsible for claims relating to the debit or credit of my (our) account including the acts or omissions of others, including the bank and clearing houses which receive and transmit the transfer instruction. Anchor is not responsible for delays in processing that may occur due to circumstances beyond our control.
Electronic Funds Transfer Authorization AgreementElectronic Funds Transfer Authorization Agreement • January 30th, 2022
Electronic Funds Transfer Authorization Agreement for ACH Credit Payment MethodElectronic Funds Transfer Authorization Agreement • February 20th, 2007
I/we hereby agree to comply with the Department’s requirements for the ACH Credit Payment method. I/we also authorize the Department to update our payment method to ACH Debit if I/we repeatedly fail to correctly complete the payment transactions in accordance with the required procedures set forth by the Department.
Electronic Funds Transfer Authorization AgreementElectronic Funds Transfer Authorization Agreement • November 14th, 2002
AUTHORIZATION AGREEMENT FOR AUTOMATIC DEPOSIT OF CHILD CARE PROVIDER PAYMENTSElectronic Funds Transfer Authorization Agreement • October 10th, 2017
This form authorizes Truist, as the official Financial Agent of ELCPH to deposit child care provider payments directly into the bank account listed below, and if necessary, reverse any incorrect credit entries made in error related to ELCPH. I agree to resubmit this form immediately if this bank or bank account changes or if I decide to stop direct deposit.
Robert Sprague Electronic Funds Transfer Authorization AgreementElectronic Funds Transfer Authorization Agreement • March 29th, 2019
PLEASE COMPLETE TAX TYPES LISTED BELOW PART I TAXPAYER INFORMATION Federal ID Number Taxpayer Name Contact Person Mailing Address Telephone Number City, State, Zip Code Fax Number Email Address Part II Tax Type □ New EFT Account □ Modify EFT Account ENTER FEDERAL ID NUMBER □ Insurance # □ IOLTA # □ Motor Vehicle Fuel # □ Public Utilities # PART III ACH DEBIT OPTION (Taxpayer phones in tax payment) Financial Institution Name Type of Account□ Checking □ Savings Transit & Routing Number Bank Account Number I hereby authorize the State of Ohio Treasurer’s Office to process ACH Debit entries from the bank account specified above. This debit will pertain only to Electronic Funds Transfer Payments for the above named taxpayer. Authorized Signature Date PART IV ACH CREDIT OPTION (Taxpayer initiates payment through their bank) I hereby request the State of Ohio Treasurer’s Office to grant authority for the above named taxpayer to initiate ACH Credit Transactions to the State Treasurer’s
ELECTRONIC FUNDS TRANSFER AUTHORIZATION AGREEMENTElectronic Funds Transfer Authorization Agreement • February 19th, 2019
VENDOR NAME (COMPANY NAME) VENDOR NUMBER (TO BE COMPLETED BY SCOTT & WHITE) ADDRESS CITY STATE ZIP ACCOUNTING/EFT CONTACT NAME TELEPHONE NUMBER FAX NUMBER IRS TAXPAYER ID (FEIN) EMAIL ADDRESS FOR REMITTANCEADVICE* (One email address only) FAX NUMBER FOR REMITTANCE ADVICE *
ELECTRONIC FUNDS TRANSFER AUTHORIZATION AGREEMENT FOR APPORTIONMENT BILLINGElectronic Funds Transfer Authorization Agreement • August 5th, 2015
WEST TENNESSEE PUBLIC UTILITY DISTRICT ELECTRONIC FUNDS TRANSFER AUTHORIZATION AGREEMENTElectronic Funds Transfer Authorization Agreement • February 2nd, 2014
This is an Agreement for Electronic Funds Transfer (EFT) between NHC Advantage Plan Missouri (“Payor”) and itsElectronic Funds Transfer Authorization Agreement • August 2nd, 2021
.MUST SELECT ONE ☐ NEW AGREEMENT ☐ CHANGE ACCOUNT ☐ CANCEL NPI NUMBER: TAX ID NUMBER: PAYEE NAME: REMIT TO ADDRESS: NAME OF PAYEE’S CONTACT: TELEPHONE: E-MAIL: PAYEE’S BANK or DEPOSITORY INSTITUTION ACCOUNT INFORMATION (US Based Banks ONLY) ACCOUNT TYPE ☐ CHECKING ☐ SAVINGS EFFECTIVE DATE OF CHANGE: BANK/DEPOSITORY INSTITUTION NAME: BANK/DEPOSITORY INSTITUTIONADDRESS: TELEPHONE: FAX: E-MAIL: BANK CONTACT NAME: BANK/DEPOSITORY ACCOUNT NAME: BANK/DEPOSITORY INSTITUTION ACCOUNT NUMBER: ABA/ROUTING NUMBER (9 DIGITS): E-MAIL ADDRESSES OF ANYONE WHO NEEDS TO BE NOTIFIED OF PAYMENTS: The undersigned Payee hereby authorizes Payor to initiate credit entries and to credit on or after the effective date specified to Payee’s above account at the above Bank (and to any additional Bank accounts of the Payee identified on addenda attached here to) that the Payee has correctly identified by ABA (American Banking Association) routing and account numbers. If
ELECTRONIC FUNDS TRANSFER (EFT) AUTORIZATION AGREEMENTElectronic Funds Transfer Authorization Agreement • May 10th, 2016
Directions: Complete all information and attach a voided check or an image of the voided check to this form. You have the option of: (1) mailing the completed form to: Accounts Payable, PO BOX 1800, Rancho Cucamonga, CA 91729-1800, (2) faxing it to (909) 890-5752 or (3) e-mail it to
ELECTRONIC FUNDS TRANSFER AUTHORIZATION AGREEMENTElectronic Funds Transfer Authorization Agreement • October 1st, 2018
OWNER NAME PHILLIPS 66 OWNER NUMBER MAILING ADDRESS (STATEMENTS, PAYMENT DETAILS, ETC..) CITY STATE ZIP CODE IRS TAXPAYER ID (FEIN, SSN) TELEPHONE FAX E-MAIL ADDRESS
AUTOMATIC PAYMENTS – ELECTRONIC FUNDS TRANSFER AUTHORIZATION AGREEMENTElectronic Funds Transfer Authorization Agreement • December 30th, 2015
Cal Poly Pomona Foundation, Inc. Financial Services-Accounts PayableElectronic Funds Transfer Authorization Agreement • December 8th, 2016
ELECTRONIC FUNDS TRANSFER AUTHORIZATION AGREEMENTElectronic Funds Transfer Authorization Agreement • March 20th, 2017
ELECTRONIC FUNDS TRANSFER AUTHORIZATION AGREEMENTElectronic Funds Transfer Authorization Agreement • February 15th, 2011
This authorization shall remain in effect until terminated upon thirty (30) days’ written notice by either Customer or Al Parsch Oil & Propane Company. Notice of termination shall in no way affect debit and/or credit entries initiated prior to actual receipt of notice. This EFT program can be terminated or modified by Al Parsch Oil & Propane Company at any time.
ELECTRONIC FUNDS TRANSFER AUTHORIZATION AGREEMENTElectronic Funds Transfer Authorization Agreement • February 1st, 2018
ELECTRONIC FUNDS TRANSFER AUTHORIZATION AGREEMENTElectronic Funds Transfer Authorization Agreement • March 1st, 2018
The undersigned customer, hereinafter referred to as "Customer," hereby authorizes SWEETWATER VALLEY OIL CO., hereinafter referred to as "Company," to initiate debit and/or credit entries to Customer's checking account with the depository set forth below. These entries may be either in the form of a paper draft or an electronic transfer.
Authorization Agreement for Automatic Transfers from Church Member Account to the Church Account (Ach Debits)Electronic Funds Transfer Authorization Agreement • October 22nd, 2021
This authorization is to remain in full force and effect until Church has received written notification from me (or either of us) of its termination in such a time and such manner as to afford Church and the Financial Institution a reasonable opportunity to act on it.
