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Payment Financial Institution Election Form
Dear Payee,
Your reimbursement settlement resulting in money due to you will be paid electronically. Funds due will be transferred to your Direct Deposit account unless otherwise elected by you. Should you desire to have your funds deposited into another account or financial institution. Please fill in the information below.
Name:__________________________________________________________
SSN:____________________________Rank:__________________________
_____ I elect to have my travel payment deposited into my Direct Deposit account on record.
_____ I elect to have my payment deposited in an account other than my Direct Deposit. (Fill in all information below.)
Bank:__________________________________________________________
Bank Address:__________________________________________________
_______________________________________________________________
Account Number:__________________________________Savings/Checking (Circle one)
Routing Number:________________________________________________
Account Holder:________________________________________________
__________________________
SIGNATURE DATE
The information being collected on this form is required under the provision of 31 U.S.C. 3322 and 31 CFR 210. This information will be used by the Disbursing Office to transmit payment data by electronic means to the individuals financial institution. Failure to provide the requested information may delay or prevent the receipt of payments through the Automated Clearing House Payment System.