MSEA Direct Deposit/ACH Authorization Agreement

Enrollment Type *

Account Information/Authorization

Name of Business or Individual Receiving Payment: *

Account Name (Bank Account Holder Name) *

Name of the account holder as it appears on the bank account where payments are to be received. Typically, this is the same as the name of the business or individual receiving payment from the line above.

Account Type *

Bank name: *

Bank Address: *

Address Line 1

Address Line 2

City

State

Zip Code

Bank Account # *

Bank routing or ABA #: *

Contact and Payment Notification

Contact name: *

First

Last

Name of person completing form

Phone number:

Notification name:

First

Last

Name of person receiving notification of payment

Email address *

Email address where you would like payment notification to be sent

Authorization

I certify that the above is true and correct, and that I, as a representative for the above name company or the individual, hereby authorize MSEA to electronically deposit payments to the designated bank account. This authority is to remain in full force and effect utnil MSEA has received written notification from the payee requesting a change or cancellation.

Authorization *

First

Last

Name of person authorizing payment

Signature *

Date *

Please attach a voided check (for checking account), deposit slip (for savings account), or direct deposit letter for bank account and ABA routing number verification. (IMPORTANT: Documentation MUST be on official company or bank letterhead and must show account and routing number. Please do NOT submit a bank statement.)

If you do not have the required documentation, then you must request it from your bank,

Copy of Voided Check or Direct Deposit Letter (On Bank or Company Letterhead) *

Click or drag a file to this area to upload.

You must attach a voided check. If you do not have any checks, you may substitute direct deposit form from your bank. You may need to contact your bank to request this form if you are unable to download it online. Any document on bank letterhead with account name, number, and routing number will suffice.