Section 1: Request for Waiver

In the event a political subdivision or officer does not wish to remit or disburse funds to the State electronically, and therefore not comply with the Indiana Auditor of State’s Settlements Department E-Payment Policy, the political subdivision or officer must request the Auditor of State (AOS) grant a waiver of the requirement. The political subdivision or officer must state the reason for requesting the waiver, and sign and verify the waiver form.

SECTION 1: REQUEST FOR WAIVER

Enter Full Name, Enter Official Title of Enter Name of Political Subdivision or Office, request a waiver of compliance with the Indiana Auditor of State’s Settlements Department E-Payment Policy for the following reason (Please check the box that applies):

1.  The political subdivision or officer does not currently have a savings or checking account and is unable to establish such an account within the geographic area of the political subdivision or officer’s primary location without payment of a service fee. ☐

NOTE: The political subdivision or officer must submit with the waiver request a written statement by the political subdivision or officer’s financial institution of the political subdivision or officer’s inability to establish an account without the payment of a fee.

2.  The political subdivision or officer’s primary location is too remote to have access to a financial institution where a direct deposit can be made. ☐

3.  The political subdivision or officer’s financial institution is unable to accept an electronic deposit or withdrawal. ☐

NOTE: The political subdivision or officer must submit with the waiver request a written statement by the political subdivision or officer’s financial institution that the financial institution is unable to accept an electronic deposit or withdrawal.

SECTION 2: AGREEMENT

☐ By checking this box, I, Enter Full Name, Enter Official Title of Enter Name of Political Subdivision or Office, am signing this waiver request electronically on Enter Date. I agree my electronic signature is the legal equivalent of my manual signature on this waiver request in conformity with the Uniform Electronic Transactions Act. By checking the box, I understand I am submitting this waiver request for the purpose of not complying with the Indiana Auditor of State’s Settlements Department E-Payment Policy. I understand AOS has the sole discretion to determine whether the facts of this particular case warrant a waiver of compliance with the Settlements Department E-Payment Policy. I understand that if this request for waiver of the Settlements Department E-Payment Policy is approved, payment(s) required to be made to the Auditor’s office may be mailed to the AOS office. However, if this request is denied, I understand I must abide by the Settlements Department E-Payment Policy. I also understand that this waiver is only valid for one year from the date entered above; and it is the responsibility of the officer or political subdivision to provide new information or request a new waiver in eleven (11) months from the date above. I understand that failure to secure an updated waiver, and therefore failure to abide by the Settlements Department E-Payment Policy, may result in being charged interest and damages if a conforming payment is not received by AOS within the time prescribed by law.

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