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Who We Are
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Retirees
Aspiring Educators
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Board of Directors
Staff
Advocacy
School Funding
Educator Voice
Racial and Social Justice
ESP Bill of Rights
Testing
Anti-Privatization Efforts
Career Resources
Professional Development
Salaries
Pensions
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MSEA Direct Deposit/ACH Authorization Agreement
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MSEA Direct Deposit/ACH Authorization Agreement
Enrollment Type
*
New Enrollment
Cancel Enrollment
Change Account Information
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
*
Checking
Savings
Bank name:
*
Bank Address:
*
Address Line 1
Address Line 2
City
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
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
*
Clear 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.
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