MSEA Direct Deposit/ACH Authorization Agreement
Contact and Payment Notification
Name of person completing form
Name of person receiving notification of payment
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.
Name of person authorizing payment
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,