| Contact Information (* denotes mandatory field) |
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* User ID/Account ID
(i.e., abc00001)
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_____________________
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*First Name
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________________________ *Last Name________________________ |
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*Address
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______________________________
______________________________
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*City
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___________________ *State_____ *Zip _________ |
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*Phone
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____________________ |
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Email Address
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______________________________________ |
Financial Institution Information
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*Name of Financial Institution
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______________________________________ |
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*Address of Financial Institution
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______________________________
______________________________
______________________________
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*Account Information
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Please send a voided check with this form for verification of your account. |
| Amount to be billed >> $16.95/month |
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Account holder's agreement:
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I hereby authorize the State of West Virginia, hereinafter called STATE, to initiate debit entries and to initiate, if necessary credit entries as adjustments for any entries in error into my Checking account indicated above and the Financial Institution named above, hereinafter called DEPOSITORY, to credit the same any amount(s) owed to me by the State of West Virginia. This authority is to remain in full force and effect until STATE has received written notification from me of its termination in such time and in such manner as to afford STATE and DEPOSITORY a reasonable opportunity to act on it. |
* Account Holder's Signature:_________________________________________
Date: _________________________________________
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