Direct Paycheck Remittance to Account Request Form Home Ownership ...

Direct Paycheck Remittance to Account Request Form Home Ownership Accelerator?

Most employers have forms available for you to ll out to remit your paycheck into your Home Ownership Accelerator account. If your employer does not have a form, you can request direct remittance of your paycheck by completing this form and taking it to your employer's payroll department along with a voided check.

Employee information

Employee name

Social Security number/Taxpayer ID

Address City Work phone (with area code)

Account information

Home Ownership Accelerator Related Processing account number

Bank routing and transit number 091071611

Date of birth (month/day/year)

Apt./Box no.

State

ZIP

Home phone (with area code)

Note ____________________________________

:091071611:1109

4XXXXXXXXX:

RTN

Check #

Account #

Authorization

I wish to remit to my account (check one):

? Entire net pay ?% of net pay ?

.00

I authorize

(employer/company name) to electronically

remit the amount stated above to my account with the nancial institution named above, in the amount selected or

indicated, and, if necessary, to initiate any adjustment to correct entries made in error. I understand this authorization

will remain in effect until I provide written authorization to cancel it.

Signature

Employer payroll department, please mail completed form to: Ameriprise Financial, Inc. P.O. Box 1661 Minneapolis, MN 55474

Date

? 2012 Ameriprise Financial, Inc. All rights reserved.

247177 A (10/12)

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