Tdi 8 Form – Fill Out and Use This PDF

TDI- 8 Website version (rev. 7-11)

RHODE ISLAND DEPARTMENT OF LABOR AND TRAINING

Temporary Disability Insurance

P.O. Box 20100

Cranston, RI 02920-0941

DIRECT DEPOSIT AUTHORIZATION /CANCELLATION

Complete this application ONLY if you would like your benefit payments electronically deposited into your existing checking or savings account, or if you are canceling the direct deposit of your benefits.

If you are currently enrolled as an Electronic Payment Card Member (debit card), your Temporary Disability Insurance benefits will be paid via the card unless you complete this direct deposit form.

Direct Deposit is an option offered to you for your convenience. Your deposit normally will be in your account forty-eight hours after the payment has been approved by the Department of Labor and Training. If necessary, contact your bank to verify the deposit.

To Elect Direct Deposit; complete all of the information requested below. If you are applying for direct deposit into a checking account, attach a CHECK MARKED “VOID” to the application. If a savings account, include any bank documentation as proof of routing and account numbers. You may have to contact your bank to obtain the bank’s Routing Number. Deposit slips are not accepted.

Check the appropriate box under Direct Deposit Authorization/Cancellation. Sign and date this application and mail it to the address listed above.

If you are canceling Direct Deposit, complete your name and social security number and check the option below to cancel, sign and date the form and mail it to the above address.

Identification Information (Please Print Clearly)

Your Name:		Social Security No:

Bank Information (Only one bank account may be entered)

Name of Your Bank:

Bank Account Type (check one):		Checking	OR		Savings

Bank Account Number: (Attach check marked “void”)

Your Bank’s Routing Number:

Direct Deposit Authorization/Cancellation

PLEASE CHECK ONE:

I authorize my net benefits to be sent to the financial institution named above to be deposited into the designated account.

I request cancellation of direct deposit.

Your Signature: ____________________________________________________Date:__________________