Laserfiche WebLink
Electronic Payment (ACH) Enrollment Form <br />Payee/Company Information (To be Completed by Payee) <br />Name: <br /> <br /> <br /> <br /> <br /> <br /> <br /> VA 22314 <br />Small Address (for payment notification only): <br />accounting@olsongroupitd.com <br />Contact Person Name: <br />Telephone Number: ( I <br />Kyle B. Olson, President <br />(703) 518-998 <br />Payee/Joint Payee Certification: <br />I certify that I am enl:ided to the payments identified with this <br />Taxpayer/Social Security number. In signing this form, I authorize i <br />payment to be sent to the financial Institution m( mined below `mod <br />d-, <br />resident <br />Signa re Title <br />deposited to the designated account. <br />Siamdure 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 Institution Information (To be Completed by Financial Institution) <br />Depositor Account Title: <br />Q1saY n �v LTA <br />Name of Financial Institution <br />7vuJ�` <br />Mailing Address on Bank Account:/ty�Ckavlcly�iz )/,,9 <br />Address of financial Institution: <br />300 A/ wkfhial JX J7/-&o >3-a_.sys <br />I3 i,n65-1. A14r4nee'-'a,V/r 223ty <br />ACEI Coordinator Nam . %% <br />Telephone -Number: ( I <br />Nine -Digit Ron <br /> <br /> <br /> <br /> <br />I confirm the tdentity of the above -named piyee(s) and the account number and title. As representative of the above -named <br />financial Institution, I certify that die financial institution agrees to receive and deposit the payment identified above In accordance <br />with 31CFR Parts 240, 209, and 210. <br />Print or Type Representative's Name: <br />/� <br />�gnatnire t^^:cn�enlntive: <br />Telephone <br />Number: <br />Date: <br />Q9 Qi7I� C �� r <br />`03 -J38- <br />2 <br />