ACCOUNT HOLDER INFORMATION. Account Holder Name: Enter the accounts holder legal name (individual or business name), as reported • to the Internal Revenue Service (IRS).
ACCOUNT HOLDER INFORMATION. Provider/Supplier/Indirect Payment Procedure ( ) Xxxxxx Legal Business Name Chain Organization Name or Home Office Legal Business Name (if different from Chain Organization Name) Account Holder’s Street Address Account Holder’s City Account Xxxxxx’s State Account Holder’s Zip Code Tax Identification Number (TIN) Designate TIN SSN (enrolling as an individual) OR EIN (enrolling as a group/organization/corporation Health Plan HPID IPP Medicare National Provider Identifier (NPI) National Provider Identifier (NPI) National Provider Identifier (NPI) NMNI Identification Number (if issued) NMNI Identifier ( CES ) or Other Entity Identifier (OEID) (CESEntities Only)
ACCOUNT HOLDER INFORMATION. IPP individual practitioner Line 1: Enter the provider’s/supplier’s/indirect payment procedure (NEO) xxxxxx’x legal business name or the name of the physician or individual practitioner, as reported to the Internal Revenue Service (IRS). The account to which Medicare. IPP CP-575 EFT payments made must bear the name of the physician or NOOCRATIC CONTRACTOR , or the legal business name of the person or entity enrolled with WORLD CREDIT.
ACCOUNT HOLDER INFORMATION. ● Account Holder Name: FIRST PERSON INC ● Account Holder DBA: FIRST PERSON ● Account Holder Business Address: 600 X XXXXX XXXX XXX 0000 XXXXXXXX XX 00000
ACCOUNT HOLDER INFORMATION. Account Holder Name: Enter the accounts holder legal name (individual or business name), as reported to the Internal Revenue Service (IRS). • DBA Name: Enter the DBA name if applicable. • Street Address: Enter the account holder’s street address. • Enter the account holder’s city, state, and zip code. • Account Holder Tax Identification Number: Enter the tax identification number as reported to the IRS. - If the business is a group, organization or corporation, provide the Federal employer identification number (EIN). - If enrolling as an individual provide your Social Security Number.
ACCOUNT HOLDER INFORMATION. Provider/Supplier/Indirect Payment Procedure (IPP) Xxxxxx Legal Business Name Chain Organization Name or Home Office Legal Business Name (if different from Chain Organization Name) Account Holder’s Practice Location Street Address Account Xxxxxx’s Practice Location City Account Xxxxxx’s Practice Location State Account Xxxxxx’s Practice Location Zip Code Tax Identification Number (designate SSN or EIN) Medicare Identification Number (if issued) Health Plan Identifier (HPID) or Other Entity Identifier (OEID) (IPP Entities Only) National Provider Identifier (NPI) National Provider Identifier (NPI) National Provider Identifier (NPI) PART III: FINANCIAL INSTITUTION INFORMATION Financial Institution’s Name Financial Institution’s Street Address Financial Institution’s City/Town Financial Institution’s State/Province Financial Institution’s Zip/Postal Code Financial Institution’s Telephone Number Financial Institution’s Contact Person Financial Institution Routing Number Provider’s/Supplier’s/IPP Entity’s Account Number with Financial Institution Type of Account (check one) Checking Account Savings Account Please include a confirmation of account information on bank letterhead or a voided check. When submitting the documentation, it should contain the name on the account, electronic routing transit number, account number and type. If submitting bank letterhead, the bank officer’s name and signature is also required. This information will be used to verify your account number.
ACCOUNT HOLDER INFORMATION. Sección 1 Información del titular de la cuenta If the address you enter in Section 1 differs from that on our records, we will update our record address. / Si la dirección que ingresa en la Sección 1 es diferente a la que aparece en nuestros registros, actualizaremos su dirección en los mismos. First Name/ Nombre Middle/ Segundo nombre Last Name/ Apellido Street Address/ Dirección City/ State/ Ciudad/ Estado Zip Code/ Código postal Social Security Number/ Número de Seguro Social Home / Mobile Telephone Number/ Número de teléfono particular/móvil Section 2 Bank Information / Sección 2 Información del banco Checking Account/ Cuenta corriente Bank Name/ Nombre del banco Routing Number/ Número de enrutamiento Account Number/ Número de cuenta Savings Account/ Cuenta de ahorros You must provide one of the following to confirm your bank account information: • A blank and unsigned check with your name pre-printed on it that has been voided (starter checks are not acceptable); or • A bank letter showing your name and bank details including account number and routing number, must be on bank letterhead. Debe brindar uno de los siguientes documentos para confirmar su información bancaria: • Un cheque en blanco y sin firmar con su nombre preimpreso que ha sido anulado (no se aceptan cheques iniciales); o • Una carta del banco en el que figure su nombre y detalles bancarios, incluidos su número de cuenta y número de enrutamiento; debe estar impresa en papel con membrete del banco. Routing number/ Número de enrutamiento
ACCOUNT HOLDER INFORMATION. Creditor or Attorney Name Postal Mailing Address City State Zip Code Telephone Number Email address Contact Person Contact Person’s Title Contact Person’s Telephone Number Contact Person’s email Address Please mail the voucher remittance to the above (Check one) □ postal mailing address. □ email address.
ACCOUNT HOLDER INFORMATION. Provider/Supplier/Xxxxxx Legal Name Chain Organization Name or Home Office Legal Name (if different from Chain Organization Name) Account Account Xxxxxx's Practice Location Street Address Account Xxxxxx's Practice Location City Account Xxxxxx's Practice Location State Account Xxxxxx's Practice Location Zip Code Tax Identification Number ( SSN or EIN) National Provider Identifier (NPI) National Provider Identifier (NPI) National Provider Identifier (NPI)
ACCOUNT HOLDER INFORMATION. Enter the appropriate information in all fields. Account Holder Name(s): Work Phone Number: Cell Phone Number: E-mail Address: Have you ever had utility service with the City of Oakland Park? Yes No If yes, please provide the service address:
