Direct Deposit Financial Enrollment/Change Form

Direct Deposit Financial Enrollment/Change Form
This form will be used to establish accurate bank account information for automatic deposit of payments.
Center's Legal Name *
ie, LLC, Inc,
DBA
Centers DBA Name if Applicable
Address*

Address

Street Address Line 2

CityState

Zip
Authorized Contact Person*
Title/Position*

OwnerDirectorAdminOther
Email Address*
example@example.com
Phone*
FEIN -Federal Employers Identification Number*
Type of Institution*

Child CareAdult CareOther
Indicate Type of Action*

Enrollment (New)Change/Add
Section II. Automatic Deposit Certification/Agreement
I authorize Youth Educational Services, Inc. to deposit my reimbursements directly into my Bank Account with   Name of Bank*
Account Type   Checking    Savings   Other*
Bank Routing Number   ROUTING* Account Number   Account #*
Please Upload a Voided Check or Direct Deposit Form from the bank

Cancelof
Information with my Account Number is provided with this form. If I change banks or my bank account, I understand that I am responsible for submitting this form indicating a change to YES Inc. I further authorize Youth Educational Services, Inc. to adjust any over/under deposit made in error to my account.
I certify that I am authorized to make this request to Youth Educational Services, Inc. I understand it is my responsibility to notify Youth Educational Services, Inc in writing within 5 business days of a change in bank or my bank account information for my organization.*

Clear
Print Name*
Title
Date*

MonthDayYear
Date
Please Note: You will be notified via mail the month the direct deposit will be entered.
Should be Empty: