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pg. 121 Appendix I – Supplier ACH-EFT Application

MISSOURI DEPARTMENT OF SOCIAL SERVICES SUPPORT DIVISION, LIHEAP SUPPLIER ACH-EFT APPLICATION SECTION A: Supplier Information *1. TYPE OF ACTION (Check Only One) o Initial Direct Deposit setup o Change Direct Deposit Information o Cancel Direct Deposit and begin payment via paper check *2. 9 DIGIT SUPPLIER NUMBER *3. SUPPLIER NAME (Please include DBA information if applicable.) *4. INFORMATION OF INDIVIDUAL COMPLETING FORM (Please print) Name: Title: Email address: *5. ADDRESS (Number, street name, city, state, and zip code) *6. TELEPHONE NUMBER (include area code) SECTION B: Financial Institution Information **Must be completed by your financial institution. **1. NAME OF FINANCIAL INSTITUTION **2. PREVIOUS ACCOUNT INFORMATION (Only complete if changing ACH-EFT information on file) Type of Account (Circle): CHECKING SAVINGS 9 Digit Routing Number:

Name of staff completing form:

Account Number:

**3. FINANCIAL INSTITUTION ADDRESS & PHONE NUMBER **4. CURRENT ACCOUNT INFORMATION (To be used for future deposits) Type of Account (Circle): CHECKING SAVINGS 9 Digit Routing Number:

Account Number:

SECTION C: Vendor Authorization I wish to participate in Direct Deposit and in doing so: • I (We) hereby authorize the State of Missouri to initiate credit entries (deposits) and to initiate, if necessary, debit entries (withdrawals), or adjustments for any credit entries made in error to my (our) account designated above. • I (We) understand that it is my (our) responsibility to notify the Family Support Division when a change in banking information is made. This notification must be made at least two (2) weeks prior to the scheduled direct deposit. Without this notification, I (we) understand that payments may be delayed.

• I (We) understand that by endorsing or depositing checks that payment is made from Federal and State funds and any falsification, or concealment of material fact, may be prosecuted under Federal and State laws.

• I (We) hereby authorize the State of Missouri to initiate payment adjustments made to this account that were intended for another vendor or another account.

• I (We) understand the State of Missouri may terminate my (our) enrollment in the Direct Deposit program if the State is legally obligated to withhold part or all payments for any reason (for example, garnishment orders).

• I (We) understand that the Family Support Division may terminate my (our) enrollment if I (we) no longer meet eligibility requirements.

• I (We) understand that this document shall not constitute an amendment or assignment of any nature whatsoever, or any contract, purchase order or obligation that I (we) may have with any agency of the State of Missouri. Suppliers must sign and date the Application to authorize initiating, changing, or canceling this Application. *SIGNATURE *DATE