3636A Form Michigan – Fill Out and Use This PDF

Michigan Department of Treasury 3636A (Rev. 3-08)

STATE OF MICHIGAN

Electronic Funds Transfer (Direct Deposit)

Authorization for Vendor Payments

Issued under P.A. 94 of 1979. Filing is voluntary.

Type of authorization (select one only)

NEW: Enter all banking information on the C&PE Web site before completing and submitting this form.

CHANGE: Enter all bank related changes on the C&PE Web site first. Then complete this form by entering changes to the financial institution, account number, or type of account; and submit the completed form. Do not close your old bank account until electronic payments are received in your new account.

CANCELLATION (Revocation): You may cancel (revoke) your prior Authorization by either inactivating your EFT authorization on the C&PE Web site or by checking this box and completing and submitting this form.

Mail completed form to: State of Michigan, Department of Management & Budget, Office of Financial Management, P.O. Box 30026, Lansing, MI 48909-0710 or fax the form to (517) 373-6458. If you have any questions, contact the Office of Financial Management, at (517) 373-4111 or (888) 734-9749.

Please print or type.

The number below is:

Individual Taxpayer ID No. (ITIN)

PAYEE INFORMATION

Social Security No. (SSN)

Federal Employer ID No. (FEIN)

1.

Payee Name

2.

SSN, FEIN or ITIN

3.

Mailing Address (Street or RR#)

4.

City, State, ZIP Code

5.

Name and Title of Contact Person

6.

E-mail Address

7. Daytime Telephone Number

8.

Financial Institution Name

9.

Routing Transit Number

10. Financial Institution Telephone Number

11. Account Holder's Name(s)

12. Account Number for Deposit of Electronic Funds Transfer

13. Account Type (Select one only)

14. Account Indicator

Checking

Savings

Consumer

Commercial

I authorize the State of Michigan to deposit payments owed to me by the State, by electronic funds transfer into the designated financial institution and account number. I also authorize the State of Michigan to make corrections from this account in the event that a deposit from the State of Michigan is made in error. Further, I agree not to hold the State of Michigan responsible for any delay or loss of funds due to incorrect information I have supplied on this authorization form. I understand this authorization remains in effect until cancellation: (a) in writing by the Payee or Payee's Authorized Signatory, (b) by the State of Michigan, or (c) by accessing your State of Michigan vendor record on the C&PE Web site and cancelling electronically.

I consent to and agree to comply with the National Automated Clearing House Association Rules and Regulations and the State of Michigan's rules about electronic funds transfers as they exist on the date of my signature on this form or as subsequently adopted, amended or repealed. Michigan law governs electronic funds transactions authorized by this agreement in all respects except as otherwise superseded by federal law.

If more than one signature is required to authorize withdrawal of funds, all must sign this form. Attach a page with additional signatures, if necessary.

15.	Print or Type Name of Payee or Payee's Authorized Signatory	16.	Title of Authorized Signatory
17.	Signature of Payee or Payee's Authorized Signatory	18.	Date
19.	Signature of Secondary Signatory(s)	20.	Date