Download the Direct Deposit Authorization Form

The Direct Deposit Authorization form should be used to perform one of the following:

• Set-Up Direct Deposit Payment
• Modify existing Direct Deposit arrangements
• Cancel Direct Deposit and re-instate payment through U.S. mail

PART A - Identification details:

• You MUST provide your Statewide Vendor Number unless this form accompanies a new registration.
• If you do not know your Statewide Vendor Number use the link provided - Statewide vendor number lookup
• You MUST provide your legal name as it appears with the IRS.
• Please provide your DBA if you have one.
• You MUST provide your Social Security Number (SSN) OR Employer Identification Number (EIN). Do not provide both.

PART B - Payment option:

• Check the box indicating your preferred method of payment.

PART C - Direct Deposit information and signature:

• If you checked Direct Deposit in Part B, fill out all fields in Part C.
• Please note that if the Account type is left blank we will default to checking account.
• Please note that if Payment type is left blank, we will default to corporate/business payment.