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Electronic Payment (ACH) Enrollment Foran <br />Payee/carnpanyTnformatfan;ak..`,`of-� .,• . <br />Name:y y <br />Renetit Administrative Services .inti Corp <br />soclai Secud�1 or Taxpayer ldentilication Number; <br />38-2.383661 <br />Addmsa: <br />9246 Portage Ind ustrial give <br />Depositor Account Number: aY Checking u Savings <br />45698895 <br />Portage MT 49927 <br />roost. Address (for payment notlncation only).^� <br />ar@1laskonlinexom <br />Contact Person Name: <br />Telephone Number i ) <br />Lonnie Millet, <br />269-418-,6275 <br />Payee/Joint Payee Certtfioedon: <br />I eertify that I ant ontitied to the payments idantm,d rvith this <br />Taxpayer/Sochi Secuoity number. In signing this farm, I authorise my <br />to be <br />nature Title <br />Payment sent to the financial Institution named below <br />deposited to the designated <br />R,..�-'�1,� t�/ r <br />amount. <br />��7,ir,t ;/+✓.s.r { <br />'t5de <br />I corm the identity of the above-named payees) and the amount number and title. As representative of tate above-named <br />finanoiat institution, I certify that thr, financial institution agrees to receive and deposit the payment identified above in accordanoe <br />pa are <br />The City of Santa Ana must be notified of any bank account changes, Failure to notify the City of such <br />changes may result In your payment being delayed. <br />Bank/Financial Inatftutionlnforma4io <br />---� <br />Depositor AccountT ATI'�� <br />13ENRFI'I'r1DMINI51'RATIVESCRVICIS INTERNATIONAL CORPORATION <br />TE CORPORATION <br />Name of Financial Institution: <br />1'IVC%ink <br />Mauling Address on Bank Account: <br />Address of Financial Institution: <br />9246 PORTAGE INDUSTRIAL. DR., PORTAGE, MI 99021 <br />249 Plfth Avenue, Pittsburgh, PA 15222 <br />ACH CoordinatorName: <br />Dylan Ford <br />Teiephonc Number: ( ) <br />317-267-3741 <br />Nine -D1git RqutingTrensit Number: <br />E E E❑ O M M <br />Depositor Account Number; 45698895 <br />Type ofAccountc Q Savings <br />-"F'- <br />M Checking <br />Pfnnncial Institutien Certificatlan; <br />'�' <br />I corm the identity of the above-named payees) and the amount number and title. As representative of tate above-named <br />finanoiat institution, I certify that thr, financial institution agrees to receive and deposit the payment identified above in accordanoe <br />with a1QrR Parts 240, 809, and 210. <br />Print or Type Representative's Nance: <br />Sig. Lure of Representative; <br />Telephone <br />Date: <br />Ott 1 R <br />�---- <br />° <br />Number: <br />317 -?G-7 --? <br />cry /3//� <br />