Indiana Direct Deposit Form 3
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Add Deposit

Change Deposit

Stop Deposit

Name of Vendor/Claimant who prepared this Request
Work Number:

State Form 47551 (2/96)

Name:

Approved by State Board of Accounts 09/1997

Home Number:

STATE OF INDIANA
AUTOMATED DIRECT DEPOSIT AUTHORIZATION AGREEMENT

1.
2.
3.
4.

Instructions:
Requestor will complete first section and have their bank/credit union complete Section 2.
The bank/credit union will complete Section 2 and return to the requestor.
Requestor will file completed form with Auditor of State, 200 West Washington St., Room 240, Indianapolis, IN 46204-2728
Requestor and depository should retain a copy. Additional blank copies are available from Auditor of State. Phone: (317) 232-3300

SECTION 1:

REQUEST AND AUTHORIZATION
,

Vendor / Claimant as shown on the account

Federal I.D. Number / Social Security Number

,
Address (Number and Street, and/or P.O. Box No.)

City, State, and Zip Code (00000-0000)

requests, pursuant to IC 4-8.1-2-7(d), to receive payment(s) by mean