Free State Instant Deposit Program Enrollment, F-80905 - Wisconsin

DEPARTMENT OF HEALTH SERVICES Division of Enterprise Services F-80905 (07/08)

STATE OF WISCONSIN

STATE INSTANT DEPOSIT PROGRAM ENROLLMENT
Completion of this form is voluntary, however, its completion will assist in accurately enrolling customers in the State Instant Deposit Program.

First time set up on ACH Change of account information Name of Payee Street Address / P.O. Box City, State, Zip Code Select Either Option A or B OPTION A - Deposit in Named Depository Depository Name Branch (if any) City, State, Zip Code When completed, mail or take to your financial institution Account Number

SECTION I
Completed by local government

OPTION B - Deposit in Local Government Pool Local Government Pool Depositor Number Sub-Account Number to be used

When completed, mail to: The Office of the State Treasurer P.O. Box 7871 Madison WI 53707-7871

I hereby authorize the State of Wisconsin, hereinafter called State, to deposit directly to the organization's demand account at the depository named above or the Local Government Pooled Investment Fund administered through the Office of the State Treasurer, hereinafter called Depository, to credit same to such account. The State is authorized to verify data directly with the Depository. I also authorize the State of Wisconsin to make debit adjustments to the same account to correct problems or errors. This authority is to remain in full force and effect until the State has received written notification from this organization to change the designated Depository in such time and in such manner as to afford State and Depository a reasonable opportunity to act on it.

Name - Treasurer (Type or Print)

Title

SIGNATURE - Treasurer

Date - Signed

Name - Deputy Treasurer (Type or Print)

Title

SIGNATURE - Deputy Treasurer

Date - Signed

NOTE: Attach a DEPOSIT TICKET or CANCELED CHECK used for the above account or copy thereof

F-80905, Page 2

STATE INSTANT DEPOSIT PROGRAM ENROLLMENT SECTION II
Completed by the financial institution

The State of Wisconsin's Instant Deposit Program is an electronic payment system designed to promptly and efficiently disburse funds using the Automated Clearing House (ACH). As part of the program, the State will begin sending ACH credits to the above customer. To help ensure that this process goes smoothly, we are asking that you review for accuracy the financial institution information which your customer supplied us. The ACH payments will be coming in the CCD+ format. This means there will be remittance information electronically transferred in addition to the payment amount. Please advise your customer of the options your financial institution offers for conveying this remittance information; e.g., hardcopy or electronic delivery and the timing of these options. Show your customer where the ACH credit will appear on the bank statement. Your signature below confirms that the above-named payee provided the correct account and routing number for their account. Your signature also confirms that the financial institution agrees to receive and deposit the payment identified above. Name - Financial Institution Street Address / P.O.Box - Financial Institution City, State, Zip Code

Routing Number (ABA Transit Number) Depositor Account Title Name - Sales Support Officer SIGNATURE - Sales Support Officer

Title Date - Signed

This completed form should be mail to the State Agency

SECTION III
Completed by the Office of the State Treasurer The above named local government (see Section I) elects to receive payments from the State Agency named to be deposited into its account in the Local Government Pooled Investment Fund. The Office of the State Treasurer verifies that the Depositor Number and subaccount number are accurate.

Routing Number (ABA Transit Number) Depositor Account Number SIGNATURE - Office of the State Treasurer

0 1

7 1

5 1

0 - 0 8 5

0 1

0 1
Date - Signed

2 6

2 6