Wisconsin Direct Deposit Form 2 - Free Download
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Wisconsin Direct Deposit Form 2
Wisconsin Direct Deposit Form 2
Type of Account Account Number Type of Account Account Number
REQUEST FOR DIRECT DEPOSIT
Section II – ACCOUNT INFORMATION
Section I – IDENTIFICATION
Name of Taxation District
Street Address
City State Zip
County - Municipal Code
IPAS Account Number
Town City
Village County
SL-201 (R. 9-12) Wisconsin Department of Revenue
Section III – CERTIFICATION I HEREBY AUTHORIZE the State of Wisconsin, hereinafter called STATE, to deposit directly to the
organization’s account at the depository named above or the Local Government Pooled Investment Fund administered through the Office of the State
Treasurer, hereinafter called DEPOSITORY, to credit same to such account. The STATE is authorized to verify data directly with the DEPOSITORY.
I also authorize 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 STATE has received written notification from this organization 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.
Print or Type Name Title
Signature Date (MM DD CCYY) Telephone Number
Contact Person’s Name Email
Option A – Local Financial Institution
Requested Effective Date (MM DD CCYY)
Option B – Local Government Pooled Investment Fund
Local Government Pool Number Local Government Pool Number
Sub-Account Number Sub-Account Number
Routing Number Depositor Acct. No. Routing Number Depositor Acct. No.
Signature – State Treasurer’s Office Date Signed (MM DD CCYY) Phone Number
STATE USE ONLY STATE USE ONLY STATE USE ONLY STATE USE ONLY
CURRENT OR 1
ST
TIME REQUESTED CHANGE
Name of Financial Institution Name of Financial Institution
Branch (if any) Branch (if any)
Street Address Street Address
City State Zip City State Zip
Bank Routing Number (9‑digits) Bank Routing Number (9‑digits)
Signature of Bank Official Date Signed (MM DD CCYY) Phone Number
Checking CheckingSavings Savings
Please read the instructions on the reverse side before completing this form.
Choose Option A or B
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