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ZBox is checked 771' form ;s not needed <br />PLEASE <br />DO NOT Statewide Payee Registration <br />STAPLE Washington State <br />TLP t: fs chis a e gsft larr or C A [ art pFi r check one -NEW REGISTRATION <br />❑✓ CHANGE to EXISTING REGISTRATION - complete the ENTIRE form and check below what is updated: <br />❑ NamefDBA F1 Address ❑ Contact Information ❑Email E] Payment Options ❑ Direct Deposit J❑ Additional Information <br />If you know your Statewide Vendor Number, enter it here: <br />KITTITAS COUNTY <br />SWV 0010475-11 <br />jBion about tine payee and contact person <br />Legal Name of Payee as it appears on federal tax forms (see W-9) <br />COUNTY GOVERNMENT <br />Business Name, if different from Legal Name above — e.g. Doing Business As (DBA) Name <br />205 WEST 5TH, STE 105 <br />Mailing Address <br />ELLENSBURG WA 98926 <br />City, ST and Zip Code <br />Emai[ to receive Statewide Vendor Number and payment notifications <br />Type of Business <br />91-6001349 <br />SSN OR EIN <br />Brett Wachsmith, Co.Treasurer <br />Contact Person <br />509-962-7535 <br />Contact Telephone Number <br />509-933-8212 <br />Contact Fax Number <br />Agy#/Owner-InL/Systemlidentifier STATE USE ONLY <br />STEP Option. <br />Drect Depos[t to bank (rerwmanded) of ❑ Ched in US mail .(terminates any previous banking information on fie) <br />r 4: For Direct De osit, cora fete al) fields betorv. of'Sr- n <br />E NAME <br />US BANK 509-952-7451 <br />Financial Institution Name — must be a US institution Financial Institution Phone Number <br />:,fir., urs <br />125000105 153505473170 <br />Routing Number—see example at right Account Number—see example at right <br />In addtion to providing ym;r banking information on this form, you may also attach a voided check. I.li�lrif#C1�li f14 = '» ��62"9'r <br />Account Type: ❑+/ Checking or Esavings (checking Wil be used if neither box is marked.) <br />routing number account ru.nber <br />(nine dig'ts) (car. vary in length) <br />Authorization for Direct Deposit: <br />I hereby authorize and req_es' the Department of Enterprise Services (DES) ar_d the Office of the Stare Treasurer (OST) to initiate credit ent les for payee <br />payments to the account indicated above, ala the financial -_zstitution named shove is authorized to credit such account. I agree to abide by the Natrona: <br />Automated C:earing House Association. (NACH3A) rules with regard to these entries. Plusuar` to tce NACHA ruEes, DES and OST tray initiate a reversing <br />entry to recal: a dup:icate or erroneous entry that they previously initiated. I understand 1_mt, 'fa reversa, action is required, DES wi'l r_c6fy this office of <br />the c: -or ar.d the reason for the reversal. :errs authority wi:: continue unti: such time DES and OST have had a reasonable opportunity to act upon written <br />.equest to terminate or change the direct deposit serv_ce initiated herein. <br />Brett Wachs ith Kittitas County Treasurer <br />Aufhcri ruts[ ve (Please Print) Title <br />March 1, 2016 <br />of Authorized Representative Date <br />