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Direct Deposit Sign Up (BAC - NU)

This document contains a direct deposit form with fields to provide payment information for direct depositing funds into a bank account, including the payee's name and contact information, type of payment being deposited, financial institution routing and account numbers. It certifies the payee is entitled to payment and authorizes the financial institution to receive and deposit the funds according to government regulations. The financial institution representative confirms the payee and account details and certifies the institution will deposit the payment.

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Cyber Gemelas
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172 views1 page

Direct Deposit Sign Up (BAC - NU)

This document contains a direct deposit form with fields to provide payment information for direct depositing funds into a bank account, including the payee's name and contact information, type of payment being deposited, financial institution routing and account numbers. It certifies the payee is entitled to payment and authorizes the financial institution to receive and deposit the funds according to government regulations. The financial institution representative confirms the payee and account details and certifies the institution will deposit the payment.

Uploaded by

Cyber Gemelas
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
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Download as PDF, TXT or read online on Scribd
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A NAME OF PAYEE (last, first, middle initial) D TYPE OF DEPOSITOR ACCOUNT CHECKING SAVINGS

E DEPOSITOR ACCOUNT NUMBER


ADDRESS (street, route, P.O. Box, APO/FPO)

CITY STATE ZIP CODE F TYPE OF PAYMENT (check only one)


Social Security Fed Salary/Mil. Civilian Pay
TELEPHONE NUMBER Supplemental Security Income Mil. Active
AREA CODE ( ) Railroad Retirement Mil. Retire
Civil Service Retirement (OPM) Mil. Survivor
B NAME OF PERSON(S) ENTITLED TO PAYMENT VA Compensation or Pension Other:_____________________
(specify)
C CLAIM OR PAYROLL ID NUMBER G THIS BOX FOR ALLOTMENT OF PAYMENT ONLY (if applicable)
TYPE AMOUNT
N/A
Prefix Suffix
PAYEE/JOINT PAYEE CERTIFICATION JOINT ACCOUNT HOLDERS` CERTIFICATION (optional)
I certificate that I am entitled to the payment identified above, and that I I certify that I have read and understood the back of this form, including the
have read and understood the back of this form. In signing this form I SPECIAL NOTICE TO JOINT ACCOUNT HOLDERS.
authorize my payment to be sent to the financial institution named below
to be deposited to the designated account.
SIGNATURE DATE SIGNATURE DATE
N/A N/A
SIGNATURE DATE SIGNATURE DATE
N/A N/A N/A N/A

SECTION 2 (TO BE COMPLETED BY PAYEE OR FINANCIAL INSTITUTION)


GOVERNMENT AGENCY NAME GOVERNMENT AGENCY ADDRESS
N/A

SECTION 3 (TO BE COMPLETED BY FINANCIAL INSTITUTION)


NAME AND ADDRESS OF FINANCIAL INSTITUTION ROUTING NUMBER CHECK
BANCO AMERICA CENTRAL MANAGUA DIGIT
THROUGH THE BANK OF NEW YORK 0 2 1 0 0 0 0 1 8
6023 AIRPORT ROAD DEPOSIT ACCOUNT TITLE
ORISKANY, NY 13424
ATTN. ACH DEPARTMENT

FINANCIAL INSTITUTION CERTIFICATION

I confirm the identity of the above-named payee(s) and the account number and title. As representative of the above-named financial institution, I certify that
the financial institution agrees to receive and deposit the payment identified above in accordance with 31 CFR Parts 240, 209, and 210.
PRINT OR TYPE REPRESENTATIVE NAME SIGNATURE OR REPRESENTATIVE TELEPHONE NUMBER DATE
(506)

Financial institutions should refer to the GREEN BOOK for further instructions.

THE FINANCIAL INSTITUTION SHOULD MAIL THE COMPLETED FORM TO THE GOVERNMENT AGENCY IDENTIFIED ABOVE.

NSN 7540-01-058-0224 1199-207

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