Vendor/Payee
Direct Deposit Authorization
Form
Instructions For Completing the Vendor/Payee Direct Deposit Authorization Form
The Direct Deposit Authorization Form should be used to perform the following:
Set-Up Direct Deposit Payment.
To change your bank account.
Cancel direct deposit and reinstate payments by check.
Note:
If writing instead of typing, please PRINT clearly in blue or black ink only. Forms will not be accepted if they
have whiteout, have been crossed off, or have been written over.
Part A – Identification Details:
You
MUST
provide
your
Statewide
Vendor
Number
unless
this
form
accompanies
a
new
registration.
If you do not know your Statewide Vendor Number use the VENDOR LOOKUP page.
You
must
provide
you
r
legal
name
as
fil
ed
with
the
IRS
.
You must provide your
DBA if you have one.
You
MUST
provide
your
Social
Security
Number
(SSN)
OR
Employer
Identification
Number
(EIN).
Part B –
Payment Option:
Check the box indicating your preferred method of payment.
Part C – Direct Deposit Information and Signature:
If you checked Direct Deposit in Part B, fill out all fields in Part C.
Your bank’s name is required.
If the Account type is left blank, we will default to Checking account.
If the Payment type is left blank, we will default to Corporate/Business payment.
Important: After confirmation, it will take three– to– five business days for your direct deposit to activate.
Signature Block:
Please sign with a pen (a “wet signature”).
Electronic, inserted or stamped signatures will not be accepted.
This form is not considered valid unless it is signed.
Submitting the Vendor/Payee Direct Deposit Authorization Form:
Please PRINT and SIGN
the completed form
SCAN
to PDF format and EMAIL
FAX to: (360) 664-3363 OR
MAIL to: Statewide Payee Registration, PO Box 41450, Olympia, WA 98504-1450.
For questions about the form, please contact the Payee Registration Unit at (360) 407-8180 ext. 5. For any
other questions, please contact the agency you are expecting payment from.
Rev. 02/2024
PLEASE DO NOT STAPLE
Vendor/Payee
Direct
Deposit Authorization Form
Important: For changes to existing banking arrangements, you will be contacted via email, telephone
number, or physical mailing address on file
to verify the change. Changes will not take effect until they
are successfully verified with the contact person on file.
PART A: Enter Identification Details – ALL FIELDS REQUIRED (Except SWV on new registration)
New registration?
Yes
(you must submit a registration form)
No
Statewide Vendor Number:
SWV
-
Legal Name:
DOING BUSINESS AS (DBA):
Taxpayer Identification Number: (SSN or EIN)
PART B: Select Payment Option
Direct Deposi
t
to
bank
(recommended).
Check
in
US
mail
(terminates
any
previous
banking
information
on
file).
PART
C: For Direct
Deposit,
complete
all
fields
below
then print
and sign
In
addition
to
providi
ng
your
banking
information
on
this
form,
you
may
also
attach
a
voided check.
Financial
Insti
tution
N
ame
– must be
a
US
insti
tution:
Financial
Insti
tution
Tel
ephone
Number
:
Routing
number
– see
exampl
e at right
:
Account
Number
– see example at right:
Account
Type:
Checking
Savings
Payment
Type:
PPD (Personal)
CCD (Corporate/Business)
Authorization for Direct Deposit
I hereby authorized and request the Office of Financial Management (OFM) and the Office of the State Treasurer (OST) to initiate credit entries for
payee payments to the account indicated above, and the financial institution named above is authorized to credit such account. I agree to abide by
the National Automated Clearing House Association (NACHA) rules with regard to these entries. Pursuant to the NACHA rules, OFM and OST may
initiate a reversing entry to recall a duplicate or erroneous entry that they previously initiated. I understand that if a reversal action is required, OFM
will notify this office of the error and the reason for the reversal. This authority will continue until such time OFM and OST have a reasonable
opportunity to act upon written request to terminate or change the direct deposit service initiated herein.
Authorized Representative (Please Print)
Title
SIGNATURE of Authorized Representative
Date: This form is valid for 90 days
Rev. 02/2024
