WA ST Military Department 10/9/2019

PLEASE sTare PRINT FORM DO NOT ;, A Office of Financial Management STAPLE . y�K Better information.Better decisions.Better government.Better Washington. �'z,A� Statewide Payee Registration Washington State Page 1 of 2 PLEASE READ BEFORE PROCEEDING -The legal name on both forms must - Please fill out this form (both pages) in its entirety, match each other and the legal name even if some information has not changed. on file with the IRS. -A 9-digit US taxpayer identification number - Please use dark blue or black ink when (either SSN or EIN) is required on both forms. signing, or if filling out the forms by hand. If you know your Statewide Vendor Number, enter it here: SWV0000348-00 STEP 1: Enter information about the •a ee and contact •erson City of Everett 91-6001248 Legal Name of Payee as It appears on federal tax forms(see W-9) SSN OR EIN Andy Lee Business Name,if different from Legal Name above—e.g.Doing Business As(DBA)Name Contact Person 2930 Wetmore Ave Suite 9H (425 ) 257-8604 Ext. Mailing Address Contact Telephone Number Everett, WA 98201 ( 425)257- 8611 City,State and Zip Code Contact Fax Number alee@everettwa.gov Email to receive Statewide Vendor Number and payment notifications STATE USE ONLY Agy#/Owner-Int/System/Identifier City government Type of Business(If Non Profit or Tax Exempt,please submit your determination letter) STEP 2: Select Payment Option: Q✓ Direct Deposit to bank(recommended)or it Check in US mail (terminates any previous banking information on file) STEP 2a: For Direct De•osit, corn•lete all fields below and si•n I t.M.Wirrtf Away Anyrtalt 567119 In addition to providing your banking information on this form,you may also attach a voided check. US Bank (206 ) 344 - 4443 MTTO laam•aop Financial Institution Name—must be a US institution Financial Institutio -Phone Number Soak PK— his account Is: ',USA 125000105 153595429009 Checking Savings Routing Number—see example at right Account Number—see example at right a d.fnoltto Cheoking If no option in chocked `1.oil Oo au* _` 6013062 Account Type: PPD(Personal) ❑✓ CCD(Corporate/Business) routing number account number Will default to Cal If no option Is checked (nine digits) (can vary in length) Authorization for Direct Deposit: I hereby authorize and request the Office of Financial Management(OFM)and the Office of the State Treasurer(OST)to initiate credit entries for payee payments to the account indicated above,and the financial institution named above is authorized to credit such account. I agree to abide by the National Automated Clearing House Association(NACHA)rules with regard to these entries. Pursuant to the NACHA rules,OFM and OST may initiate a reversing entry to recall a duplicate or erroneous entry that they previously initiated. I understand that,if a reversal action is required, OFM will notify this office of the error and the reason for the reversal. This authority will continue until such time OFM and OST have had a reasonable opportunity to act upon written request to terminate or change the direct deposit service initiated herein. Andy Lee Accounting Manager Authorized Representative(Please Print) Title (Notto�ed by your financial institution) 10/7/2019 SIGVATURE of Authorized Representative Date (No stamped or electronic signatures please)