Direct Deposit Payment Setup Form
Freeport Housing Authority | 815-232-4171 ext. 1012
Type:
*
Company
Person
Company/Vendor Name:
*
Contact Name:
*
First Name
Last Name
Contact Phone Number:
*
-
Area Code
Phone Number
Contact E-mail:
*
Name of Financial Institution:
*
Type of Account:
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Checking
Savings
Routing Number:
*
Account Number:
*
Please consider attaching a voided check or deposit slip to ensure accuracy. Any questions regarding this form, contact Brenda Westfall at 815-232-4171 ext 1012 or bwestfall@hacf.us.
Direct Deposit Notification E-mail:
*
Effective Date:
*
-
Month
-
Day
Year
Date
Authorized Signature:
*
Print Authorized Signature:
*
Mr.
Ms.
Mrs.
Dr.
Prefix
First Name
Last Name
Submit
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Should be Empty: