Direct Deposit Authorization For Electronic Funds Transfer (EFT)

Direct Deposit Authorization for
Electronic Funds Transfer (EFT)

Please upload this form to your RentHelpMN account at:
apply.renthelpmn.org
or mail to:
RentHelpMN
Document Services Center Fax: 952-285-2318
1055 American Boulevard, Suite A Instructions for completing this form are on the back.
Bloomington, MN 55420 Please print clearly and use black ink.
Mailing Address (General)
Name WANDA COLE
Address 605 W 8TH ST
City PINEVILLE State MO Zip Code 6 4 8 5 6
Contact Information - Please list person who can respond if additional information is required.
Contact Name WANDA COLE
Email Address Lisamaxi69@gmail.com
Email address for payment notification Lisamaxi69@gmail.com

(if different from above)
Phone - - Ext
Tax Identification Information
Federal ID/Social Security Number 4 9 4 8 6 8 6 3 6
Federal ID/Social Security Name EDWARD WILES
Financial Institution Information Note: Do not use /, \, *, - or ~ in any fields in this section. Replace with spaces.
ABA Routing Number 1 2 4 3 0 3 1 2 0
Customer Account Number 7 9 3 0 0 0 9 0 8 0 5 8
Financial Institution G R E E N D O T
Street Address
City, State, ZIP Code

Type of Account: Checking Savings
Authorization to Make Electronic Fund Payments
I authorize the Minnesota Housing Finance Agency, Dakota County, Hennepin County, Ramsey County, Washington County, and the
cities of Minneapolis and Saint Paul, and their successors and assigns, collectively referred to as RentHelpMN, to deposit, by electronic
fund transfer, payments owed to me by RentHelpMN and, if necessary, debit entries and adjustments for any amounts deposited
electronically in error. RentHelpMN shall deposit the payments in the financial institution and account designated above. 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
maybe erroneously transferred electronically.
I consent to and agree with the National Automated Clearing House Association Rules and Regulations and RentHelpMN's Ruleabout
electronic transfers as they exist
Verified on the date of my signature on this form or as subsequently adopted, amended or repealed.
by PDFFiller
Authorized Signature Printed Name10/22/2021 TitleOWNER Date10/22/2021
12-03-2021 00:00
Completing the Direct Deposit Authorization for Electronic Fund Transfer (EFT) Form
Notice of Intent to Collect Private Data Financial Institution Information

All payment recipients are asked to provide private data to the Minnesota 1. ABA Routing Number. Enter the ABA Routing Number to identify
Housing Finance Agency, Dakota County, Hennepin County, Ramsey County, your financial institution. Contact your bank if you are not sure
Washington County, the cities of Minneapolis and Saint Paul, and their what number to put in this field.
successors and assigns, hereafter referred to collectively as RenHelpMN, for 2. Customer Account Number. Enter your bank account number.
the following purposes.
State employees who support this function of the state’s accounting system Contact your bank if you are not sure what number to put in this
need to access the data to verify information. Others who have legal access to field.
the data include: Legislative Auditor, Attorney General, enforcement agencies 3. Financial Institution Name, Address, City, State, Zip Code. Enter the name
with statutory authority, and any other person or entity authorized by law or and address of your financial institution.
court order. 4. Type of Account. Indicate if the account listed on this form is a
checking or savings account.
Social Security Number (SSN) or Federal Employee Identification
Number (FEIN): Needed for identification purposes. This number is
Authorization to Make Electronic Fund Payments
used to match recipients with payments. This number is also called a
Tax Identification Number or TIN number. You are not legally required Sign the form and print your name and title (if any) and
to provide this data. However, without this information we cannot the date.
convert you to EFT.
Send the Form
ABA Routing Number, Account Number, Account Type: This data is Please upload this form to your RentHelpMN account at:
required to correctly deposit payments to your designated bank apply.renthelpmn.org
account. You are required by law to provide this information.
Incomplete information may cause a delay in converting to EFT. or mail to:
Additionally, incorrect information may cause a payment to be delayed RentHelpMN
or deposited to the wrong account. Document Services Center
1055 American Boulevard, Suite A
Instructions for Completing the Form Bloomington, MN 55420
Determine which bank accounts will be used for direct deposit. A
separate copy of the Electronic Fund Transfer Authorization form is or
required for each bank account. Fax: 952-285-2318
To change your ACH payment information complete a new ACH

Mailing Address (General)
form and upload to your RentHelpMN account, or mail or fax
Name, Address, City, State, Zip Code. Enter the name of the
the form using the information above.
business or individual, address, city, state, and zip code.
Contact Information
Enter the name, email address, and phone number of the person
who can respond to questions regarding the information provided on
this form.
Tax Identification Information

Federal ID/ Social Security Number and Name. Enter the nine-digit
Federal Employer Identification Number (FEIN) for business, or the
nine-digit Social Security Number (SSN). Enter the name associated
with either the FEIN or SSN listed on the form.

Direct Deposit Authorization For Electronic Funds Transfer (EFT)

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Direct Deposit Authorization for

Electronic Funds Transfer (EFT)

Name WANDA COLE

Address 605 W 8TH ST

City PINEVILLE State MO Zip Code 6 4 8 5 6

Contact Name WANDA COLE

Email Address Lisamaxi69@gmail.com

Email address for payment notification Lisamaxi69@gmail.com

Federal ID/Social Security Number 4 9 4 8 6 8 6 3 6

Federal ID/Social Security Name EDWARD WILES

ABA Routing Number 1 2 4 3 0 3 1 2 0

Customer Account Number 7 9 3 0 0 0 9 0 8 0 5 8

City, State, ZIP Code

Authorized Signature Printed Name10/22/2021 TitleOWNER Date10/22/2021

Notice of Intent to Collect Private Data Financial Institution Information

To change your ACH payment information complete a new ACH

Tax Identification Information

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