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Fill and Sign the Medical Forms Online Health Care Form Templates

Fill and Sign the Medical Forms Online Health Care Form Templates

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Reset Form Print Form REQUEST TO DISCONTINUE DIRECT DEPOSIT To: OFFICE OF THE STATE CONTROLLER ATTN OSC ACCOUNTING 14 STATE HOUSE STATION AUGUSTA ME 04333-0014 Phone 207-626-8420 Fax 207-626-8447 Please use the New/Change EFT form to change bank account information. This form is to only deactivate standard EFT. This form is not for use with PayMode updates. Please contact PayMode directly. You are hereby requested to discontinue electronic payments to the following: Payee's Name EIN TIN of Payee SSN Circle ONE Taxpayer ID Number of Payee Contact Person's Name If different from Payee or Name on Act Payee or Contact's Phone # Address of Payee (Street/PO, City, State, & Zip) Contact Email OLD Bank Info: Name on Account Transit/ABA # Name of Financial Institution Account # Savings Address of Financial Institution Checking Circle ONE (Street/PO,City, State,Zip & Phone) Date Signature of Payee (Benefit Recipient) or Authorized Agent (not a fill-in, must sign after printing) You MUST notify us in writing when there is a change in your name, address, authorized agent, bank acount, etc.. INCOMPLETE FORMS WILL NOT BE PROCESSED

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