Form-Eft1 - Direct Deposit Application Form printable pdf download

MAIL WITH VOIDED CHECK TO: VA DMAS Programs, Public Partnerships, LLC, 4991 Lake Brook Drive, Suite G90, Glen Allen, VA 23060

Public Partnerships, LLC - Virginia DMAS Programs

FORM -EFT1

DIRECT DEPOSIT APPLICATION

(for use with checking, savings, and personal debit card

direct deposit requests only)

CREATE OR CHANGE PPL EFT ACCOUNT CLOSE EXISTING PPL EFT ACCOUNT

Check the appropriate box below based on your request.

New Direct Deposit Set-up

Change Account Number

Cancellation Request

Change Account Type

Change Financial Institution

PAYEE INFORMATION

Disclosure of your Social Security Number (SSN) is voluntary pursuant to 42 USC 405c2C. PPL will use to file required information returns to IRS.

1 Federal Employer Identification No. (EIN)

EIN

2 Social Security Number (SSN)

SSN

3 Payee Name

4. Telephone Number

5 Payee Address

6 City

7 State

8 Zip

AUTHORIZATION FOR SET-UP, CHANGE OR CANCELLATION

I authorize PPL to stop making electronic transfers to my account without advance notice. I certify that I'm

authorized to contract for entity receiving deposits per this agreement, & that all information provided is accurate.

9 Signature (Required)

10 Title

11 Date

I authorize PPL to process payments owed to me for services authorized by a VA DMAS Program in the Commonwealth of Virginia. Per my request, PPL

will deposit my payment directly to my bank account indicated below using Automated Clearing House (ACH) transaction. I recognize that if I fail to

provide complete and accurate information on this form, processing may be delayed or made impossible, or my electronic payments may be

erroneously made. I certify I have read and agree to comply with PPL rules governing payments and electronic transfers. I authorize PPL to withdraw

from the designated account all amounts deposited electronically in error. If the designated account is closed or has an insufficient balance to allow

withdrawal, then I authorize PPL to withhold any payment owed to me by PPL until the erroneous deposited amounts are repaid. If I decide to change

or revoke this authorization, I recognize that I must forward such notice to PPL.

ACCOUNT DETAIL INFORMATION

12 Financial Institution Name (My Bank's Name)

13 Bank Address

15 Account Type

14 Bank Routing Number

Checking

Savings Your Debit Card

16 My Account Number

17 Bank City

18 Bank State

19 Bank Zip

CANCELLATION

PPL Use ONLY

Staff Entry:

Cancellation Reason

Date:

I do not have access to the PPL Web Portal, please send a Pay Stub.

Form-Eft1 - Direct Deposit Application Form

Related Articles

Related forms

Related Categories