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Direct Deposit Authorization Form
Securely submit your banking details for ACH payments to CCRC. Complete all required sections below.
Provider Information
Enter your details as they appear on your W-9.
Check Appropriate Box
*
NEW
CHANGE
Do you have a business name?
*
Yes
No
Name (must match W-9 line 1)
Business name/disregarded entity name (must match W-9 line 2)
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Tax Identification Number (must match W-9): Please provide either SSN or EIN. At least one is required.
Enter either your SSN or EIN. Only one is required.
Social Security Number (SSN)
EIN
Address (Number & Street)
*
Apt./Unit #
City
*
State
*
Zip Code
*
Email
*
example@example.com
APID Number (For CCRC Use Only)
Bank Information
Provide your banking details for ACH direct deposit.
Bank Name
*
Account Type
*
Checking
Savings
Bank Account Number
*
Bank Routing Number
*
Attach pre-printed voided check or bank verification
*
Upload a File
Drag and drop files here
Choose a file
Cancel
of
No temporary checks, handwritten verifications, must match W-9, credit union must show actual account number.
Authorization
Please read and sign to authorize direct deposit.
By signing below, I (the Provider) authorize CCRC to initiate direct deposit (ACH) credits and, if necessary, debit corrections to the bank account listed above in accordance with NACHA rules. This authorization remains in effect until CCRC receives written notice of cancellation. I certify the information provided is correct and matches my W-9.
Signature
*
Date
*
-
Month
-
Day
Year
Date
Which CCRC location would you like your document sent to
*
San Fernando Valley
Antelope Valley
Victorville
San Bernardino
Submit Authorization
Submit Authorization
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