Florida Direct Deposit Form 1 - Free Download
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Florida Direct Deposit Form 1
Florida Direct Deposit Form 1
DFS-A1-26E rev.12/2010
STATE OF FLORIDA
DIRECT DEPOSIT PAYMENT AUTHORIZATION
State of Florida Vendor Use Only
Please complete this form and return to: Direct Deposit Section
Department of Financial Services
200 East Gaines Street
Tallahassee, Florida 32399-0359
PAYEE INFORMATION
Name: Federal Tax ID Number: -
Address: OR Social Security Number *: - -
Direct Deposit Action Requested: (Please check one)
Start Change
* The social security number is required to be collected pursuant to 26 USC 6109, and will only be used for the purpose of complying
with filing requirements imposed by the Internal Revenue Code and to comply with Section 119.071(5)(a)7, F.S.
PAYEE CONTACT INFORMATION
Name: Telephone Number: ( ) Ext:
E-Mail Address: Fax Number: ( )
NOTE: ALL SIGNATURES MUST BE ORIGINAL. NO COPIES OR FAXES WILL BE ACCEPTED.
AUTHORIZATION:
I hereby authorize Direct Deposit Section to verify with the Financial Institution the accuracy of the account information provided. I
hereby authorize the State of Florida to initiate credit entries and, if necessary, a debit entry in order to reverse a credit entry made in
error, in accordance with NACHA rules (Article II, Sections 2.4 and 2.5.) I hereby authorize these payment instructions, and accept the
terms and conditions for Electronic Funds Transfer payments on the reverse side of this form.
Authorized Signature: Title:
Printed Name: Date:
FINANCIAL INSTITUTION INFORMATION:
Financial Institution Name: Telephone: ( )
Address: Account Name:
Account Type: Checking Savings
ACCOUNT INFORMATION:
Transit Routing Number of Your Financial Institution: Your Account Number (Start at the left, leave unused spaces blank):
IAT
Please check this box if your funds are deposited in a U.S. financial institution and the entire amount is subsequently forwarded
to a financial institution in a foreign country. See the instructions page on the reverse side of this form for further explanation
on IAT (International ACH Transactions).
FINANCIAL INSTITUTION VERIFICATION - (MUST BE COMPLETED BY YOUR FINANCIAL INSTITUTION BEFORE SUBMITTING)
I have verified that the account and transit-routing numbers provided above are correct. I have further verified that the person signing
as the payee is an authorized signer on the account specified above.
Print Name: Title of Bank Officer:
Signature of Bank Officer: Date:
Bank Officer Telephone Number: ( ) Ext:
For Florida Department of Financial Services Use Only:
DM: COMP: FC: VVC:
VMP: VV: VB: APPR:
Comments:
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