STATE OF MINNESOTA
DIRECT DEPOSIT AUTHORIZATION
* Please print clearly and use only BLUE or BLACK ink * / Direct Deposit Authorization Form Number
PART 1: Provide The General Mailing Address
Name
Address
City
State / MN / Zip Code / Vendor Number
PART 2: Provide A Contact Person
Contact Name
Phone
Fax
E-Mail

**Please provide your E-Mail address for us to notify you of your PIN number

PART 3: Invoice Reference

Up to 30 characters of ‘Vendor Invoice’ information will be included with each stub line embedded in the EDI-820 being sent to your bank. Enter any helpful tips that will assist you in crediting the appropriate account.

PART 4: Must Provide Tax Identification
Federal ID
Federal ID Name

Enter the Federal ID Name exactly as it appears on your SS-4 (Corporate) or Social Security Card (Individual)

State of MN ID
PART 5: Authorize The State To Make Direct Deposit Payments

I authorize the Commissioner of the Department of Finance to deposit by electronic transfer payments owed to me by the State of Minnesota and, if necessary, debit entries and adjustments for any amounts deposited electronically in error. The Commissioner shall deposit the payments in the financial institution and account designated below. I recognize that if I fail to provide complete and accurate information on the authorization form, the processing of the form may be delayed or my payments may be erroneously transferred electronically.

I consent to and agree with the National Automated Clearing House Association Rules and Regulations and the Commissioner’s rule about electronic transfers as they exist on the date of my signature on this form or as subsequently adopted, amended or repealed.

Authorized Signature / Printed Name / Title / Date
PART 6: Provide Financial Institution Information

*NOTE: Do not use the '/', '\', '*' or '-' characters in any field of this section. They will be replaced with spaces.*

ABA Routing Number / 0 / 9 / 1 / 0 /  / 0 / 0 / 0 / 2 /  / 2
Customer Account Number / 1 / 8 / 0 / 1 / 4 / 0 / 7 / 9 / 8 / 3 / 6 / 4
Financial Instiution Name / U / S / B / A / N / K
Address / 6 / 0 / 1 / S / E / C / O / N / D / A / V / E / . / S / O / U / T / H
City / M / I / N / N / E / A / P / O / L / I / S / State / MN / 5 / 5 / 4 / 0 / 2
Type of Account / x / Checking / Savings
Customer Name for the CTX File