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ALL REQUIRED FIELDS MUST BE COMPLETED TO AVOID RETURN OF THE APPLICATION AND-OR DELAY IN PROCESSING. RETURN COMPLETED FORM AND ATTACHMENT TO: FSD, ATTN: LIHEAP P.O. Box 2320; Jefferson City, MO 65102 Fax 573-522-9557 INSTRUCTIONS FOR COMPLETING THE SUPPLIER ACH-EFT APPLICATION SECTION A - All fields in Section A are required fields. 1. Type of Action (Check Only One) – Check the box for the action you would like to accomplish by completing the Application. • Initial Direct Deposit setup – Check this box if this is a new request for direct deposit or if you previously had a direct deposit, but it has since closed, and you would like to re-open the request. • Change Direct Deposit Information – Check this box to notify us of any change in the direct deposit request, including, but not limited to, change in routing number or account number, change in contract name, etc. • Cancel Direct Deposit – Check this box to notify us to cancel the direct deposit. When the request to cancel the direct deposit is processed, you will no longer receive payments via electronic funds, but will begin to receive paper checks if you are entitled to payment. 2. Supplier Number – please include all 9 digits 3. Supplier Name – name of business, to include DBA if applicable 4. Information of Individual completing form – please print name, title and email address of person completing form for correspondence. 5. Supplier address – please include number, street name, state, and zip code 6. Telephone number – include area code SECTION B - All fields in Section B are required fields. 1. Name – Input the name of your financial institution. 2. Previous Account Information -- Type of Account (Check Only One) • Checking Account – Check this box if payment is to be direct deposited into a checking account. • Savings Account – Check this box if payment it to be direct deposited into a savings account. 3. Financial Institution Address and phone number – Input the address and phone number of your financial institution, including number, street name, city, state, and zip code. 4. Current Account Information – enter full routing number and account number and circle if this is a checking or saving account • If you are submitting a voided check, the 9-digit routing number can be found at the bottom of your check. The 9-digit routing number is the first set of 9 numbers found at the bottom of the check, towards the left side. • If you are submitting a voided check, the account number can be found at the bottom of your check after the 9-digit routing number or after the check number. SECTION C Signature Individual and – Individual must sign and date on this line. In order to allow the Family Support Division and the State of Missouri, Division of Finance and Administrative Services to deposit payments into an account, you must complete all of the required fields on the Application and attach a voided check or an official letter from your financial institution stating your name, the bank routing number, and your account number. Starter checks and counter checks will not be accepted in place of a check or letter from your financial institution. With the exception of your signature(s), type or print the required information. WHAT YOU CAN EXPECT . The Application will be processed when a complete form is received, including all required fields and an attached voided check or letter from your financial institution. . Failure to complete all required fields on the Application and attach a voided check or letter from your financial institution will cause the application to be returned to you for correction and will delay processing of the application. 3. You should begin receiving payments by direct deposit approximately 10-14 days after the Application has been processed. 4. If you are entitled to any payments during the time it takes to process the Application, the payments will be issued as paper checks. CHANGING FINANCIAL INSTITUTIONS OR ACCOUNTS Payments will continue to be deposited in the designated account at your financial institution until you notify the Family Support Division you wish to change the financial institution and-or account where the payments are deposited. To make any changes to the financial institution and-or account where payments are deposited, you must complete a new Direct Deposit Application. All parties listed on the contract and-or listed as business owners, must review and sign, to authorize changes (including cancellations), to the Direct Deposit Application. Failure to notify the Family Support Division of a change in account information will result in a delay in receiving your payments.