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R"�'4 srnre <br /> on <br /> 1 <br /> a o <br /> STATE OF WASHINGTON _ a� <br /> STATEWIDE VENDOR REGISTRATION & <br /> DIRECT DEPOSIT AUTHORIZATION <br /> (FORM W9 ALSO REQUIRED) <br /> • <br /> CITY OF EVERETT ANDY LEE <br /> Vendor Name Contact Person <br /> Account with State is already established. Accounting Supervisor <br /> Payment/Direct Deposit Notification Address Title <br /> - (425)257-8604 Ext. <br /> City State Zip+4 /Telephone Number <br /> ( ) - <br /> E-mail Address to Send Direct Deposit Notification Fax Number <br /> Primary Type of Goods or Services Headquarters Office Dun&Bradstreet DUNS fit <br /> Direct Deposit Information F, M.Wired <br /> '' <br /> BANK OF AMERICA - Julie Firnstahl (206)358 -3991 <br /> Financial Institution Name&Phone Number -,-.4-' ,rigof Ai or <br /> 123308825 wAMPLE <br /> Routing Number ` ;'-' <br /> 105000006323 ,...� <br /> Account Number tER44Dtiltb 6013062 <br /> ® Checking ❑ Savings (Checking will be used if neither box is marked.) routing number account number <br /> is nine digits can vary in lenath <br /> I hereby authorize and request the Office of Financial Management (OFM) and the Office of the State Treasurer(OST) to <br /> initiate credit entries for vendor payments to the account indicated above, and the financial institution-Wanted-abav-e—i <br /> authorized to credit such account. I agree to abide by the National Automated Clearing House Association (NACHA) rules <br /> with regard to these entries. Pursuant to the NACHA rules,OFM and OST may initiate a reversing entry to recall a duplicate <br /> or erroneous entry that they previously initiated. I understand that, if a reversal action is required, OFM will notify this office <br /> of the error and the reason for the reversal <br /> This authority will continue until such time OFM and OST have had a reasonable opportunity to act upon written request to <br /> terminate or change the direct deposit service initiated herein. <br /> a-k-1 d , i-e-e...„ <br /> Authorization Name oAccount Title v <br /> 4l d1 Lek._ 3/ l� <br /> Authorization Sign ure on Account Date <br /> Account with State is already established. <br /> Revised 10/30/03 SWV00 0 0 3 4 8 - 0 0 <br /> See Page 2 for PRIVACY NOTICE —— <br /> 169 <br />