COCA Payment Authorization Form

This form only authorizes payment from COCA. Most of the information needed to complete this form can be found on your checks or deposit slips.

"*" indicates required fields

Payee Name*

Direct deposits will not be made to an account held in a different name from the payee.

Payee Address*

Street Address Address Line 2 City State ZIP Code

Payee Phone*

Payee Email*

Financial Institution Information and Certification

Provide the payee’s account number and account name or title exactly as they appear in the financial institution’s records.

Name of Financial Institution*

Account Name*

9 Digit Routing Number*

Found on the bottom left of your check.

Account Number*

Located at the bottom of your check after the 9 digit routing number.

Payee Certification*

By checking this box, I am confirming my electronic signature to authorize payments to be sent to the financial institution named above and deposited to the designated account. I have read and accept the Terms and Conditions for Direct Deposit Participation.

The bank account information will remain confidential to the extent provided by law and necessary to make Direct Deposit payments. This form authorizes COCA to initiate credit and, if necessary, debit entries and adjustments for any credit entries made in error to the account indicated at the depository financial institution named and to credit or debit the same from such account. This authority will remain in effect until canceled in writing. Further, the origination of Automated Clearing House (ACH) transactions to the account must comply with state and federal law and regulations provisions.

Cancellation
This authorization remains in effect until canceled by the payee. Upon cancellation by the payee, the payee should also notify the receiving financial institution of the cancelation. COCA also reserves the right to discontinue Direct Deposit at any time.

The financial institution may cancel this authorization by giving the payee a written notice 30 days before the cancellation date. However, a cancellation by the financial institution for fraud shall be effective immediately. The payee must immediately advise COCA if the financial institution cancels the authorization. Violating these terms and conditions may cause, at a minimum, Direct Deposit termination.

Changing Recipient’s Financial Institution
The payee’s direct deposit authorization will remain in effect until withdrawn in writing with sufficient notice to COCA to allow adequate time to effect termination. COCA will not be responsible for any loss arising solely because of error, mistake, or fraud regarding the information provided on this Direct Deposit Payment Authorization form.
If the payee or authorized representative changes their financial institution, the payee must resubmit this form to COCA. Any changes to the existing direct deposit authorization, such as the bank account number, will cancel the original authorization. Grantees must complete a new Direct Deposit Payment Authorization form to re-enroll. It is recommended that the payee maintain the previously authorized account until the transition is complete.