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EFT DIRECT DEPOSIT AUTHORIZATION FORM <br />State of Colorado OSC Form Rev 912009 <br />SECTION I - DEPOSITOR STATE AGENCY INFORMATION <br />RETURN THIS FORM TO: <br />STATE AGENCY _ . _ (—% W C-S <br />MAILING ADDRESS. <br />CITY, STATE, ZIP <br />AGENCY CONTACT PHONE <br />Office of the <br />State Controller <br />&am" <br />SECTION II - PAYEE (jRECEIVOR) INFORMATION <br />VENDORNAME WeA T"C men+a on SA&Lt- rdG"4-__.___. <br />D /B /A <br />MAILING ADDRES �� 1 q <br />U� <br />/ CITY, STATE�54�0 ZIP Cam, re e.I � C.) <br />PHONE CQ�o 33b - J EMAIL C��f�ncca h r\ c r N. .CW ecA' o -- <br />CONTACT �c- 1i1C -1 K.l 1 MQ_Can n or <br />SECTION III — FINANCIAL INSTITUTION AND ACCOUNT INFORMATION: <br />ATTACH AN ORIGINAL VOIDED CHECK OR A BANK LETTER. BANK <br />LETTER MUST INCLUDE ALL INFORMATION REQUESTED IN SECTION III. <br />DEPOSITORY INSTITUTION NAME: <br />BRANCH LOCATION (CITY B STATE). � J W4--r1 M <br />TRANSIT/ ABA NUMBER 1_2A -0 -002 q:?) ACCOUNT # 00 - Ol — Ql)O(V I LQ 8O CHECKING ACCOUNT SAVINGS ACCOUNT <br />PAYEE SOCIAL SECURITY NUMBER ON BANK ACCOUNT <br />OR <br />PAYEE EMPLOYER IDENTIFICATION ON BANK ACCOUNT <br />FOR FURTHER CREDIT TO ACCOUNT <br />SECT , ON IV - AUTHORIZATION FOR DIRECT DEPOSIT SETUP, CHANGE, OR CANCELLATION: <br />ET UP CHANGE CANCEL EFFECTIVE DATE ft / / a <br />I (we) certify I have the authority to execute this authorization. I (we) hereby authorize the depositor named at top of this <br />form to Initiate, change or cancel EFT credit entries (deposits), and if necessary to reverse any Incorrect EFT payments made In <br />error to the bank account Indicated above. In the event a "reversal" can not be Implemented, I (we) understand the state will <br />utilize any other lawful means to recover the deposited funds to which the payee was not entitled. I (we) and the depositor agree <br />to be bound by National Automated Clearing House Association (NACHA) Rules. <br />This authorization Is to remain In full force until the State Depositor Agency named above has received written notification from me <br />of termination in such time as to afford a reasonable opportunity to act on it or until the record is Inactive for two or more years and <br />Is purged from the state payable system. <br />PRINTED NAME , qe l� Carnsnon TITLE �nanac <br />OSC USE ONLY: OSC DATA ENTRY DATE <br />Date h. /V / � 2- <br />BY: <br />