Name of Vendor/Claimant who prepared this Request
State Form 47551 (2/96)
Approved by State Board of Accounts 09/1997
STATE OF INDIANA
AUTOMATED DIRECT DEPOSIT AUTHORIZATION AGREEMENT
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
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