State Form 53788 2009-2026

Reset Form Name and telephone number of the person who completed this document must be provided. VENDOR INFORMATION Name State Form 53788 R2 / 10-09 Approved by Auditor of State 2009 Approved by State Board of Accounts 2009 Daytime telephone number Print or Type Legal Name Owner of the EIN or SSN as name appears on your tax return. Do not enter the business name of a sole proprietorship on this line. Trade Name Doing Business as Name D/B/A Complete only if payment is to be made payable to the DBA name Remit Address number and street city state and ZIP code Purchase Order Address Optional number and street city state and ZIP code Enter 9-digit Taxpayer Identification Number TIN of the legal name SSN Social Security Number EIN Employer Identification Number Individual s SSN - - or EIN - Check legal entity type A box must be checked in this section* Check only one box. Individual Sole Proprietorship Partnership Estate / Trust Note Show above the name and number of the legal trust or estate not personal representatives Other Limited Liability Company LLC attach IRS Form 8832 if applicable Joint Venture Club etc* Corporation Do you provide legal or medical services Yes No Government or Government operated entity Organization Exempt from Tax under Section 501 a One box must be checked Add Deposit I am a U*S* Person including a U*S* resident alien I am not a U*S* Person a W-8 must be filed with the Auditor of State Change Deposit Indiana law I. C. 4-13-2-14. 8 requires that YOU receive PAYMENT S by means of electronic transfer of funds. SECTION 1 AUTHORIZATION According to Indiana law your signature below authorizes the transfer of electronic funds under the following terms Account Holder s Name Account Number Type of Account Checking Demand Savings Please check this box if your direct deposit will be automatically forwarded to a bank account in another country. The financial institution identified below agrees to accept automated deposits under the terms set forth herein Name of Financial Institution Telephone Address Number and Street and/or P. O. Box No* Financial Institution s Authorized Signature City State and ZIP Code 00000-0000 Title ABA Transit-Routing Number Date SECTION 3 ELECTRONIC NOTIFICATION OF ELECTRONIC FUND TRANSFER EFT DEPOSITS Complete this section only if you are requesting electronic notification* You may provide up to four email addresses. I hereby request that all future notices of EFT deposits to the bank account specified above be sent to the following email addresses I agree to the provisions contained on the reverse side of this form* NAME print or type AUTHORIZED SIGNATURE TITLE DATE TELEPHONE NUMBER ATTACH A NON-ALTERED VOIDED CHECK HERE SECTION 2 FINANCIAL INSTITUTION S APPROVAL Attach a non-altered voided check or have your financial institution complete this section REQUEST FOR VENDOR INFORMATION THIS FORM APPLIES TO YOU IF YOU ARE A U*S* person including a U*S* resident alien and A person business or other entity who has or will receive a payment from the state or A state employee who has or will receive a payment other than payroll from the state.