FINANCIAL INSTITUTION INFORMATION. Financial Institution Name: Enter your Financial Institution’s name (this is the name of the bank or qualifying depository • that will receive the funds).
FINANCIAL INSTITUTION INFORMATION. Financial Institution Name* Official name of the provider’s financial institution. Financial Institution Routing Number* A 9-digit identifier of the financial institution where the provider maintains an account to which payments are to be deposited. Enter the number twice for validation. Provider’s Account Number With Financial Institution* Provider’s account number at the financial institution to which EFT payments are to be deposited. Enter the number twice for validation. Type of Account at Financial Institution* Check the type of account funds are to be deposited to. Enter the number twice for validation. Account Number Linkage to Provider Identifier (Select one and Fill in the Number) Provider preference for grouping (bulking) claim payments – much match preference for v5010X12835 remittance advice. NOTE: EFT data will always be linked by the MO HealthNet trading partner ID related to the NPI/taxonomy.
FINANCIAL INSTITUTION INFORMATION. Name of Financial Institution Address _ (Routing/Transit No.) (Checking or Savings Account No.) Please enclose a voided check or copy of check
FINANCIAL INSTITUTION INFORMATION. Financial Institution Name Financial Institution Street Address City Account Type: Checking Savings State Zip Code Routing Number Account Number Routing Number Account Number Signature I certify that I am the HSA Accountholder or an individual authorized to execute this transaction. I have read and understand the instructions and any rules or conditions relating to this transaction. I assume full responsibility for this transaction and will not hold EBS- RMSCO, Inc. or Healthcare Bank, a division of Bell State Bank & Trust liable for any adverse consequences that may result. I have not received tax or legal advice from EBS-RMSCO, Inc. or Healthcare Bank and, if necessary, will seek the advice of a tax or legal professional to ensure my compliance with related laws. All information provided by me is true and correct and may be relied upon by EBS-RMSCO, Inc. and Healthcare Bank. Signature of HSA Accountholder Date Instructions HSA DISTRIBUTION REQUEST FORM
FINANCIAL INSTITUTION INFORMATION. Financial Institution Name Official name of the provider’s financial institution Required Financial Institution Routing Number A 9-digit identifier of the financial institution where the provider maintains an account to which payments are to be deposited Required Type of Account at Financial Institution The type of account the provider will use to receive EFT payments, e.g., Checking, Saving Required Provider’s Account Number with Financial Institution Provider’s account number at the financial institution to which EFT payments are to be deposited Required Account Number Linkage to Provider Identifier Provider preference for grouping (bulking) claim payments – must match preference for v5010 X12 835 remittance advice Required Submission Information Reason For Submission Check appropriate box. Please note that EFT cannot be cancelled. Optional The signature of an individual authorized by the provider or its agent to initiate, Authorized Signature modify or terminate an enrollment. May be used with electronic and paper- based manual enrollment Written Signature of Person Submitting Enrollment A (usually cursive) rendering of a name unique to a particular person used as confirmation of authorization and identity Required Printed Name of Person Submitting Enrollment The printed name of the person signing the form; may be used with electronic and paper-based manual enrollment Optional Printed Title of Person Submitting Enrollment The printed title of the person signing the form; may be used with electronic and paper-based manual enrollment Optional Submission Date The date on which the enrollment is submitted Optional Revised 12/11/13 State of Oklahoma Department of Corrections Laboratory Contract Signature Page When signed by both parties below, this constitutes agreement and acceptance of all terms and conditions contained in the Laboratory Contract. The DOC and the facility further agree that the effective date of the Contract is the effective date denoted on the copy of the executed Signature Page returned to the facility. The original of the signed document will remain on file in the office of the Department. By signing, both parties agree that this document shall become part of the Contract.
FINANCIAL INSTITUTION INFORMATION. If account is already on file, enter amount you would like deposited per pay. If account is NOT on file, fill in all fields and attach a voided check or proof of account information. Account on File Bank Name Routing Number Account Number Amount per Pay Yes / No $ Date: Participant's Signature: Accepted by Plan Administrator
FINANCIAL INSTITUTION INFORMATION. Financial Institution Name Location of Financial Institution (City/Sate) Routing Transit Number Account number Account Name Check one: Checking Account Savings Account Please attached one of the following to evidence proof of account: Check one: Void Check Bank Letter or Specification Sheet Authorized Signature(s) Name Date Authorized Signature(s) Name Date Attached Void Check **Please return the completed form Via mail: Ouachita Hills College
FINANCIAL INSTITUTION INFORMATION. Financial Institution’s Name Telephone number Postal Mailing Address City State Zip Code Financial Institution Contact Person Contact Person’s Title Contact Person’s Telephone Number Contact Person’s Email Address Account name Routing number Account number Type of Account (check one) □Checking □Savings You must include with this EFT Authorization Agreement a voided check or a letter from the financial institution on financial institution letterhead specifying the account holder’s name, the financial institutions electronic routing transit number, account number, and account type. If submitting a letter from the financial institution on financial institution letterhead, a financial institution officer’s name and signature is also required. This information will be used to verify your account number and ownership.
FINANCIAL INSTITUTION INFORMATION. Section - Financial institution prints or types the name and address of the payee/company's financial institution who will receive the ACH payment, ACH coordinator name and telephone number, nine-digit routing transit number, depositor (payee/company) account title and account number. Also, the box for type of account is checked, and the signature, title, and telephone number of the appropriate financial institution official are included. Burden Estimate Statement The estimated average burden associated with this collection of information is 15 minutes per respondent or record keeper, depending on individual circumstances. Comments concerning the accuracy of this burden estimate and suggestions for reducing this burden should be directed to the Financial Management Service, Facilities Management Division, Property and Supply Branch, Room B-000, 0000 Xxxx Xxxx Xxxxxxx, Xxxxxxxxxxx, XX 00000 and the Office of Management and Budget, Paperwork Reduction Project (1510-0056), Washington, DC 20503. ATTACHMENT J-12 AWARD TERM INCENTIVE OPTION PLAN AWARD TERM INCENTIVE OPTION PLAN (ATIOP) For Ready Reserve Force (RRF) Ship Manager Contracts Awarded Under Solicitation DTMA8R04004 Approved by Term Determining Official Procuring Contracting Officer TABLE OF CONTENTS PART I - INTRODUCTION A. Overview
FINANCIAL INSTITUTION INFORMATION. Financial Institution's Name Financial Institution's Street Address Financial Institution's City Financial Institution's Location State Financial Institution's Zip 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
