
14. Account Indicator13. Account Type (Select one only)
Michigan Department of Treasury
3636A (Rev. 3-08)
Type of authorization (select one only)
NEW: Enter all banking information on the C&PE Web site before completing and submitting this form.
Mail completed form to: State of Michigan, Department of Management & Budget, Office of Financial Management, P.O. Box 30026,
Lansing, MI 48909-0710 or fax the form to (517) 373-6458. If you have any questions, contact the Office of Financial Management, at
(517) 373-4111 or (888) 734-9749.
I authorize the State of Michigan to deposit payments owed to me by the State, by electronic funds transfer into the designated
financial institution and account number. I also authorize the State of Michigan to make corrections from this account in the event that
a deposit from the State of Michigan is made in error. Further, I agree not to hold the State of Michigan responsible for any delay or
loss of funds due to incorrect information I have supplied on this authorization form. I understand this authorization remains in effect
until cancellation: (a) in writing by the Payee or Payee's Authorized Signatory, (b) by the State of Michigan, or (c) by accessing your
State of Michigan vendor record on the C&PE Web site and cancelling electronically.
I consent to and agree to comply with the National Automated Clearing House Association Rules and Regulations and the State of
Michigan's rules about electronic funds transfers as they exist on the date of my signature on this form or as subsequently adopted,
amended or repealed. Michigan law governs electronic funds transactions authorized by this agreement in all respects except as
otherwise superseded by federal law.
If more than one signature is required to authorize withdrawal of funds, all must sign this form. Attach a page with additional
signatures, if necessary.
Checking ConsumerSavings Commercial
Social Security No. (SSN) Federal Employer ID No. (FEIN)
The number below is:
15. Print or Type Name of Payee or Payee's Authorized Signatory
17. Signature of Payee or Payee's Authorized Signatory
19. Signature of Secondary Signatory(s)
16. Title of Authorized Signatory
18. Date
20. Date
8. Financial Institution Name
11. Account Holder's Name(s)
9. Routing Transit Number
12. Account Number for Deposit of Electronic Funds Transfer
10. Financial Institution Telephone Number
1. Payee Name
3. Mailing Address (Street or RR#)
5. Name and Title of Contact Person
2. SSN, FEIN or ITIN
4. City, State, ZIP Code
6. E-mail Address 7. Daytime Telephone Number
STATE OF MICHIGAN
Electronic Funds Transfer (Direct Deposit)
Authorization for Vendor Payments
Issued under P.A. 94 of 1979. Filing is voluntary.
Please print or type.
CHANGE: Enter all bank related changes on the C&PE Web site first. Then complete this form by entering changes to the financial institution,
account number, or type of account; and submit the completed form. Do not close your old bank account until electronic payments are
received in your new account.
CANCELLATION (Revocation): You may cancel (revoke) your prior Authorization by either inactivating your EFT authorization on the C&PE Web
site or by checking this box and completing and submitting this form.
PAYEE INFORMATION
Individual Taxpayer ID No. (ITIN)