MORAVIAN CHURCH IN AMERICA, SOUTHERN PROVINCE



MORAVIAN CHURCH IN AMERICA, SOUTHERN PROVINCE

PROVINCIAL TREASURER’S OFFICE

459 SOUTH CHURCH ST

WINSTON-SALEM, NC 27101

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DIRECT-DEPOSIT SIGN-UP FORM

Name of Payee (last,first,middle initial) _______________________________________

Address ________________________________________________________________

City ___________________________State_________________Zip Code____________

Social Security Number ___ __ ___

Employment Location(Church, Daycare or Agency)______________________________

Type of Depositor Account/Amount: Checking ____________ Savings ____________

Checking Depositor Account Number: __ __ __ __ __ __ __ __ __ __ __ __ __ __

Savings Depositor Account Number: __ __ __ __ __ __ __ __ __ __ __ __ __ __

PAYEE CERTIFICATION:

I certify that I am entitled to the payment identified above. I authorize my payment to be sent to the financial institution named below to be deposited and any adjustments made to the designated account. I can terminate the direct deposit of this payroll arrangement simply by giving written notice.

SIGNATURE___________________________ DATE________________

Name and Address of Financial Institution:

Name_______________________________

Address_____________________________

______________________________

______________________________

.

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(HAVE YOUR BANK FILL IN THE INFORMATION BELOW)

Or: Send back to the Treasurer’s Office with this form a blank void check, savings deposit slip or both if the monies are being split between a checking and savings account

Routing Number Checking: __ __ __ __ __ __ __ __ __

Routing Number Savings: __ __ __ __ __ __ __ __ __

I confirm the identity of the above-named payee and the account number. As representative of the above-named financial institution, I certify that the financial institution agrees to receive and deposit the payment identified.

Signature of Representative__________________________ Date_____________

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