Laserfiche WebLink
Electronic Payment (AC HI Enrollment Form <br /> Payee/Company Information(To be Co pX®tet4 by Pay"-_7ffi � <br /> 71— <br /> ]Name: d g� Social e sty a or i r<ti cation Number: <br /> ch <br /> Addres �,�fr. � � Depositor Account iNy�mtlet� h ng b Savings <br /> Email Address(for payment notification only): <br /> eja r" <br /> Cont rson Nam jTolehuane Number: ) <br /> Payee/ pint Payee Certification: �ounderlPPt� ident <br /> l certify that I am entitled to the payments identified writh this <br /> Taxpayer/Social Security number. in signing this form, I authorize my Title <br /> payment to be sent to the financial institution named below and <br /> deposited to the designated account. fd [r _ <br /> Title <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 Knatitution WormatiWITO be Completed by Financial Institution) <br /> Depositor Account Title: Name of Financial Institution: <br /> Mailing Address on Bank Account: Address of Financial institution: <br /> ACH Coordinator Name: 'Telephone Number:{ { <br /> Nine-Digit Routing Transit Number: <br /> 0 11 1:10 D 0 El 0 El <br /> Depositor,Account Number: <br /> Type of Account: 0 Savings 0 Checking <br /> Financial Institution Certification: <br /> I confirm the identity of the above-named payee(s) and the account number and title. As representative of the above named <br /> financial institution, I certify that the financial institution agrees to receive and deposit the payment identified above in accordance <br /> with 31 CFR parts 240,209,avid 210. <br /> Print or Type Representative's Name: Signature of Representative: 'Telephone pate: <br /> Number: <br /> Page 16 of 20 <br />