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

DEPARTMENT OF HEALTH SERVICES Division of Enterprise Services F-80905T (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

SECTION I
Completed by Tribe / Great Lakes Inter-Tribal Council (GLITC) Name of Tribe or Council Street Address / P. O. Box City, State, Zip Code

Deposit in Named Depository Depository Name Branch ( if any) City, State, Zip Code Account Number

When completed, mail or take to your financial institution

I hereby authorize the State of Wisconsin, hereinafter called State, to deposit directly to the Tribe or GLITC demand account at the depository named above, hereinafter called Depository, and to credit same to such account. The State is authorized to verify data directly with the Depository. I also authorized 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 the Tribe or GLITC 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 ­ Authorized Representative (Type or Print) SIGNATURE ­ Authorized Representative

Title Date ­ Signed

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

F-80905T, 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 customer listed on page 1. 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 will be coming in the CCD+ format. This means there will be remittance information electronically transferred in addition to the payment amount. Please advise you 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-names 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 mailed 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

0 1

7 1

5 1

0 8

­ 0 5

0 1

0 1

2 6

2 6

SIGNATURE ­ Office of the State Treasurer

Date ­ Signed