Ordinance 2014-66 - Laserfiche WebLink

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Confidential NO HEALTH WAYS ncc Hcr.ilth ( are Tw't (hmille 1. AUTHORIZATION AGREEMENT FOR ELECTRONIC PAYMENTS I authorize Healthways, LLC, to deposit, by electronic funds transfer, payments owed to me by Healthways, LLC and, if necessary, debit entries and adjustments for any amounts deposited electronically in error. Healthways shall deposit the payments in the financial institution and account designated below. I recognize that if I fail to provide complete and accurate information on this authorization form, the processing of the form may be delayed or my payments may be erroneously transferred electronically. This authority is to remain in full force and effect until Healthways, LLC has received written notification from me of its termination in such time and in such manner as to afford Healthways, LLC a reasonable opportunity to act upon it. To receive payments electronically, you must print, complete this form, and attach a voided check. PRINT ALL INFORMATION Date: Location ID (if known): PAYEE NAME: FEDERAL ID #/SOCIAL SECURITY #: DEPOSITORY (BANK) NAME: BRANCH PHONE #: CITY, STATE: ROUTING /TRANSIT #: ACCOUNT #: This account is: E Checking ❑ Savings NOTE: A VOIDED CHECK OR DOCUMENTATION MUST ACCOMPANY THIS FORM TO VERIFY BANK ACCOUNT NUMBERS BUSINESS EMAIL ADDRESS for payment notification (required) E -MAIL ADDRESS: AUTHORIZED SIGNATURE: PRINTED NAME: TITLE: DATE: ATTACH VOIDED CHECK OR PRINTED DOCUMENT FROM FINANCIAL INSTITUTION FOR VERIFICATION (REQUIRED) ---------------------------------------------------------------------------------------- - ---------------------------------------------------------------------- ----------------- MAIL TO: Healthways Contracts Dept. - INTERNAL USE ONLY - 1445 S. Spectrum Blvd., Ste. 100 SFDC Vendor ID SFDC Site Code Chandler, AZ 85286 Oracle Vendor ID Oracle Site Code