REASON FOR SUBMISSION. See Instructions on Page 3 New Enrollment Change Enrollment Cancel Enrollment Document Included: Voided Check Bank Letter Account Holder Legal Name: DBA Name if different from above: Legal Address: number, street, and apt. or suite no. City: State: Zip Code: Account Holder Tax Identification Number (9 digits EIN or SSN) EIN: SSN:
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Sources: Electronic Funds Transfer (Eft) Authorization Agreement, Electronic Funds Transfer (Eft) Authorization Agreement