Florida Direct Deposit Form 1Florida Direct Deposit Form 1
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STATE OF FLORIDA
DIRECT DEPOSIT PAYMENT AUTHORIZATION
State of Florida Vendor Use Only
Please complete this form and return to:

PAYEE INFORMATION
Name:
Address:

Direct Deposit Section
Department of Financial Services
200 East Gaines Street
Tallahassee, Florida 32399-0359

Federal Tax ID Number:
OR Social Security Number *:
Direct Deposit Action Requested: (Please check one)
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* The social security number is required to be collected pursuant to 26 USC 6109, and will only be used for the purpose of complying
with filing requirements imposed by the Internal Revenue Code and to comply with Section 119.071(5)(a)7, F.S.

PAYEE CONTACT INFORMATION
Name:
E-Mail Address:
NOTE:

Telephone Number:
Fax Number:

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Ext:

ALL SIGNATURES MUST BE ORIGINAL. NO COPIES OR FAXES WILL BE ACCEPTED.

AUTHORIZATION:
I hereby authorize Direct Deposit Section to verify with the Financial Institution the accuracy of the account information provided. I
hereby authorize the State of Florida to