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Electronic Payment (ACH) Enrollment Form <br /> Payee/Company Information(To be Completed by Payee) <br /> Nome: M(ke4#o, ! Social �Lyz r nti cation Number: <br /> Addres �lw. Depositor A_ayccount ld,Nymtlec h�ckung n Savings <br /> Y'� B (MY 2- <br /> Email Address(for payment notification only): <br /> LL61--S2L/ —0 <br /> 0/_�C_cc Lk-4 gir _YmcY-eZ&r <br /> cunt rson Name, Tel. hone Number: ) <br /> {/�l�i 1 <br /> Payee/Joint Payee Certification: Founder/President <br /> certify that I tam entitled to the payments identified with this <br /> Taxpayer/Social Security number. In signing this form, I authorize my Title <br /> payment to be sent to the Gneacial institution named below and <br /> deposited to the designated amount. u (i��✓ <br /> to i t e <br /> The City of Santa Ana must be notified of any bunk account changes. Failure to notify the City of such <br /> changes may result in your payment being delayed. <br /> Bank/Financial Institution Inflo +Eation(To 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 RoutingT'ransit Number: <br /> Depositor Act.•ount Number: <br /> Type of Account: ❑ Savings ❑ Checking <br /> Financial institution Certification: <br /> I confine the identity of the. above-named payee(s) and the account ru Tabor and title. As representative of the above-reamed <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,and 210. <br /> Print or Type Representative's Name: Signature of Representative: Telephone Date: <br /> Number: <br /> Page 16 of 20 <br />