Instructions For The Completion Of The Second Injury Fund Electronic Funds Transfer Enrollment Form

Completing The Enrollment Form:

You are to complete the unshaded portions of the enrollment form. Please complete the fields of the form with the following information:

• Vendor Name - the name of your company or organization as it appears on the bank account referenced.
  
  
• Vendor Address - the mailing address of your organization to which all payments are sent.
  
  
• Vendor FEIN/SSN - the Federal Tax Identification Number or Social Security Number of your organization.
  
  
• ABA NO/CHCK Digit - the 9-digit routing code of the financial institution for the specified savings or checking account to which funds will be deposited. If funds are deposited into your checking account, the routing number usually precedes your checking account number on the bottom of your checks.
  
  
• Bank Account Number - the bank account to which funds are to be deposited.
  
  
• Bank ACCT DESCR - general description of the bank account.  Example: "Company XYX corporate checking account".
  
  
• Bank Name - the name of the financial institution to which funds will be deposited.
  
  
• Bank Address(lines 1 -3) - the mailing address of the financial institution to funds will be deposited.
  
  
• City/State/Zip - the City/State/Zip for the mailing address listed
  
  
• Bank Telephone Number - the telephone number of the branch or bank office to contact for assistance with transmission problem resolution.
  
  
• Check/Savings Ind - Circle the appropriate letter.  "C" denotes the account information provided is for a checking account, and "S" denotes a savings account.
  
  
• Preparer's Signature - the signature of the individual completing this form.
  
  
• Print Name - Print or type the name of the individual completing this form.
  
  
• Title - the title of the individual completing this form.
  
  
• Date - the date that the form is completed.
  
  
• Phone Number - the telephone number of the individual completing the form.
  
  

NOTE:  Please include a copy of a voided check as verification of account information.

Download The Electronic Fund Transfer Enrollment Form. (PDF)

(This form is semi-interactive and may be filled out online.)