Direct Deposit Form

Lee K. Hight Administration Building
326 West 9th Street | Post Office Box 1428
Rome, Georgia 30162-1428
Tel: 706.291.0780 | Fax: 706.295.0376

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[{"type":"header","subtype":"h2","label":"Account Information","className":"d-block"},{"type":"file","required":true,"label":"Attach a voided check or letter from bank or debit card company (deposit slips or copy of debit card will not work). <br><br>MUST BE A CHECKING ACCOUNT.<br><br>Please select one or more files for upload. You may upload up to 20 files (35 Mb max). Files can be PDF, JPG, JPEG format. To upload multiple files, please hold control while clicking on multiple files before clicking \"Open\".","name":"Attach-a-voided-check-or-letter-from-bank-or-debit-card-company-deposit-slips-or-copy-of-debit-card-will-not-workMUST-BE-A-CHECKING-ACCOUNT","subtype":"file","multiple":true,"className":"d-block"},{"type":"radio-group","required":true,"label":"1. Please Check One:","inline":true,"name":"1-Please-Check-One","className":"d-block","values":[{"label":"New Direct Deposit","value":"New Direct Deposit"},{"label":"Change Direct Deposit","value":"Change Direct Deposit"},{"label":"Cancel Direct Deposit","value":"Cancel Direct Deposit"}]},{"type":"paragraph","subtype":"p","label":"2. Vendor/Payee Information","className":"d-block"},{"type":"text","required":true,"label":"Payee First Name:","name":"Payee-First-Name","className":"col-md-6","subtype":"text"},{"type":"text","required":true,"label":"Payee Last Name:","name":"Payee-Last-Name","className":"col-md-6","subtype":"text"},{"type":"text","required":true,"label":"Address:","name":"Address","className":"col-md-6 col-lg-3","subtype":"text"},{"type":"text","required":true,"label":"City:","name":"City","className":"col-md-6 col-lg-3","subtype":"text"},{"type":"select","required":true,"label":"State:","name":"State","className":"col-md-6 col-lg-3","values":[{"label":"Alabama","value":"AL"},{"label":"Alaska","value":"AK"},{"label":"Arizona","value":"AZ"},{"label":"Arkansas","value":"AR"},{"label":"California","value":"CA"},{"label":"Colorado","value":"CO"},{"label":"Connecticut","value":"CT"},{"label":"Delaware","value":"DE"},{"label":"District of Columbia","value":"DC"},{"label":"Florida","value":"FL"},{"label":"Georgia","value":"GA","selected":true},{"label":"Hawaii","value":"HI"},{"label":"Idaho","value":"ID"},{"label":"Illinois","value":"IL"},{"label":"Indiana","value":"IN"},{"label":"Iowa","value":"IA"},{"label":"Kansas","value":"KS"},{"label":"Kentucky","value":"KY"},{"label":"Louisiana","value":"LA"},{"label":"Maine","value":"ME"},{"label":"Maryland","value":"MD"},{"label":"Massachusetts","value":"MA"},{"label":"Michigan","value":"MI"},{"label":"Minnesota","value":"MN"},{"label":"Mississippi","value":"MS"},{"label":"Missouri","value":"MO"},{"label":"Montana","value":"MT"},{"label":"Nebraska","value":"NE"},{"label":"Nevada","value":"NV"},{"label":"New Hampshire","value":"NH"},{"label":"New Jersey","value":"NJ"},{"label":"New Mexico","value":"NM"},{"label":"New York","value":"NY"},{"label":"North Carolina","value":"NC"},{"label":"North Dakota","value":"ND"},{"label":"Ohio","value":"OH"},{"label":"Oklahoma","value":"OK"},{"label":"Oregon","value":"OR"},{"label":"Pennsylvania","value":"PA"},{"label":"Rhode Island","value":"RI"},{"label":"South Carolina","value":"SC"},{"label":"South Dakota","value":"SD"},{"label":"Tennessee","value":"TN"},{"label":"Texas","value":"TX"},{"label":"Utah","value":"UT"},{"label":"Vermont","value":"VT"},{"label":"Virginia","value":"VA"},{"label":"Washington","value":"WA"},{"label":"West Virginia","value":"WV"},{"label":"Wisconsin","value":"WI"},{"label":"Wyoming","value":"WY"}]},{"type":"text","required":true,"label":"Zip Code:","name":"Zip-Code","className":"col-md-6 col-lg-3","subtype":"text"},{"type":"text","label":"Contact Person's Name (if different than payee):","name":"Contact-Persons-Name-if-different-than-payee","className":"col-md-6","subtype":"text"},{"type":"text","label":"Telephone Number:","name":"Telephone-Number","className":"col-md-6","subtype":"text"},{"type":"text","subtype":"email","required":true,"label":"Email","name":"email","className":"col-md-6"},{"type":"text","subtype":"email","required":true,"label":"Email Confirmation","name":"email-confirmed","className":"col-md-6"},{"type":"paragraph","subtype":"p","label":"3. Financial Institution Information:","className":"d-block"},{"type":"text","required":true,"label":"Bank Name:","name":"Bank-Name","className":"col-md-6","subtype":"text"},{"type":"text","required":true,"label":"Bank Address:","name":"Bank-Address","className":"col-md-6","subtype":"text"},{"type":"text","required":true,"label":"Name on Bank Account:","name":"Name-on-Bank-Account","className":"col-md-6","subtype":"text"},{"type":"text","required":true,"label":"Bank Account Number:","name":"Bank-Account-Number","className":"col-md-6","subtype":"text"},{"type":"text","required":true,"label":"Nine-Digit Bank Routing/Transit Number (ABA):","name":"Nine-Digit-Bank-RoutingTransit-Number-ABA","maxlength":9,"className":"col-md-6","subtype":"text"},{"type":"text","required":true,"label":"Type of Account:","description":"The account must be a checking account or some type of prepaid debit card.","name":"Type-of-Account","className":"col-md-6","subtype":"text"},{"type":"paragraph","subtype":"p","label":"4. Approvals/Authorizations:","className":"d-block"},{"type":"checkbox-group","required":true,"label":"I certify that the information provided on this form is correct, and I hereby authorize Northwest Georgia Housing Authority's Accounts Payable to electronically credit/deposit payments to the bank account designated above (or debit from the account to correct erroneous credits). It is my responsibility to notify NWGHA AP (apinvoices@nwgha.com or (706) 368-5821) immediately if I believe there is a discrepancy between the amount deposited to my bank account and the amount of the invoice(s) paid. I understand that I must notify NWGHA AP in writing immediately of any changes in status or banking information. I understand that this authorization will remain in full force and effect until NWGHA AP has received written notification requesting a change or cancellation and has had reasonable opportunity to act on it, which should take no longer than seven (7) to ten (10) business days.","name":"I-certify-that-the-information-provided-on-this-form-is-correct-and-I-hereby-authorize-Northwest-Georgia-Housing-Authoritys-Accounts-Payable-to-electronically-creditdeposit-payments-to-the-bank-account-designated-above-or-debit-from-the-account-to-correct-erroneous-credits-It-is-my-responsibility-to-notify-NWGHA-AP-apinvoicesnwghacom-or-706-368-5821-immediately-if-I-believe-there-is-a-discrepancy-between-the-amount-deposited-to-my-bank-account-and-the-amount-of-the-invoices-paid-I-understand-that-I-must-notify-NWGHA-AP-in-writing-immediately-of-any-changes-in-status-or-banking-information-I-understand-that-this-authorization-will-remain-in-full-force-and-effect-until-NWGHA-AP-has-received-written-notification-requesting-a-change-or-cancellation-and-has-had-reasonable-opportunity-to-act-on-it-which-should-take-no-longer-than-seven-7-to-ten-10-business-days","className":"d-block","values":[{"label":"I certify.","value":"I certify. "}]},{"type":"text","required":true,"label":"Signature:","placeholder":"By typing your name you are signing this form.","name":"Signature","className":"col-md-6","subtype":"text"},{"type":"date","required":true,"label":"Date of Signature:","name":"Date-of-Signature","className":"col-md-6"}]

Direct Deposit Form

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