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<br />County of Hawai`i <br />OFFICE OF HOUSING AND COMMUNITY DEVELOPMENT <br />EXISTING HOUSING DIVISION <br />1990 Kino`ole Street, Suite 105 Hilo, Hawai`i 96720-5293 <br />V/TT (808) 959-4642 FAX (808) 959-9308 <br />E-mail: <br />DIRECT DEPOSIT AUTHORIZATION FORM <br />OHCD USE: <br />PART I: TRANSACTION TYPE <br />Date Received Payee Number <br /> New Authorization. <br /> Change in Authorization. <br />Effective Date Initials <br /> Cancellation of Authorization. <br />PART 2: PAYEE IDENTIFICATION: <br />Owner Tax ID (Social Security Number or Employer Identification Number) Contact Telephone Number: <br />Payee Name Email Address <br />Payee Mailing Address City State ZIP Code <br />PART 3: PAYEE FINANCIAL INSTITUTION INFORMATION <br />Financial Institution Name City State ZIP Code <br />Routing Transit Number Customer Account Number Type of Account <br /> Checking Savings <br />PART 4: AUTHORIZATION FOR SET UP, CHANGES OR CANCELLATION <br />I hereby request and authorize the HAWAII COUNTY HOUSING AGENCY to deposit payments by electronic fund transfer into the <br />account specified below and, if necessary, debit entries and adjustments for any amounts deposited electronically in error. I <br />recognize that, if I fail to provide complete and accurate information on this authorization form, the processing of the form may be <br />delayed or that my payments may be erroneously transferred electronically. <br />This authorization will remain in effect until written notice to terminate is given. The undersigned must allow a reasonable amount of <br />time for initiating or terminating Direct Deposit and is responsible for notification of any change in financial institution information. <br />Authorized Signature Printed Name Date <br />For New or Change in Authorization: Attach a voided check or another valid bank document, which bears the <br />name and address of the landlord, routing number and account number magnetically encoded on the form. Starter <br />checks and deposits slips are unacceptable. <br />If you have questions or concerns, please call the OHCD Existing Housing Division at (808) 959-4642. <br />Attach bank document here. <br />1584sslh updated 2/17/09 <br />