Part 1 to be completed by the Agency

Agency Name:________________________________________Agency Number:___________________

Contact Name: ________________________________________FEIN/SSN# ______________________

Title: _______________________________________________Tel. # __________________

Address:  ___________________________________________Fax # ___________________

___________________________________________________

City:  _______________________________________________State: ____Zip: __________

I hereby authorize the State of Connecticut (hereinafter "State") to electronically deposit any payments made through the Office of the State Comptroller's Accounts Payable Division to the bank account specified below. This authorization is to remain in full force and effect until the State has received written notification from me of its termination in such time and manner as to afford the State and the bank named below a reasonable opportunity to act upon it.

I have read, understand, and agree to the above statement.

Signature:___________________________________ Date: __________________

Part 2 to be completed by the Agency's Financial Institution

Bank Name: ______________________________________________________________

Routing & Transit #:(ABA#):

Account #:

Account Type:__________

I hereby certify the information provided above is complete and accurate.

Bank's Authorized Signature: _______________________________  Date: _________________________

Name (Printed): __________________________________________ Tel. # _________________________

Part 3 For office use only

Date received: _________ Bank Notification date: ______ Pre-Note date: _______Verified: ___________

Vendor File : _______________ Verified by: ________________

Implemented: _________ Live Tran: __________ Verified with:____________________on__________

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