AUTHORIZATION AGREEMENT 
                           FOR DIRECT DEPOSIT OF EFT PAYMENTS 

ƒ  To sign up for EFT, please TYPE or PRINT the information requested in SECTIONS 1-3. The information provided must be legible. SECTION 4 
   must be signed & dated. Please return original form to:  Ohio Shared Services, ATTN: Vendor Maintenance, 4310 E. Fifth Avenue, 
   Columbus, OH  43219. 
ƒ  Please attach a copy of a voided check (if a savings account, a letter from your bank stating your account & routing number). If changing banking 
   information, SECTION 3 must be completed with new financial information. 
ƒ  Any account changes must be reported to Ohio Shared Services thirty (30) days prior to actual change. 
ƒ  Payee must keep Ohio Shared Services informed of any name, address, or bank changes in order to receive important information about benefits 
   and remain qualified for payments. 
  SECTION 1 
  TYPE OF TRANSACTION:                      ADD                          CHANGE                          DELETE 

  NAME OF COMPANY OR INDIVIDUAL:                                                                                                

  ADDRESS:                                                                                                                      

  CITY STATE & ZIP:                                                                                                             

  PHONE:                                               EMAIL:                                                                   

  FEDERAL TAX ID/SOCIAL SECURTIY:                                            

  SECTION 2 – CURRENT FINANCIAL INFORMATION 

  FINANCIAL INSTITUTION NAME:                                                                          PHONE:                      

  ADDRESS:                                                                                                                      
  TYPE OF ACCOUNT:                                        SAVINGS                                       CHECKING 
   
  TRANSIT ROUTING/ABA NUMBER:                                            

  ACCOUNT NUMBER AT ABOVE INSTITUTION:                                                                            
  SECTION 3 – NEW FINANCIAL INFORMATION 

  FINANCIAL INSTITUTION NAME:                                                                          PHONE:                   

  ADDRESS:                                                                                                                      
  TYPE OF ACCOUNT:                                        SAVINGS                                       CHECKING 

  TRANSIT ROUTING/ABA NUMBER:                                            

  ACCOUNT NUMBER AT ABOVE INSTITUTION:                                                                            

OBM-1234                                                                                                                       REV. 8/21/2009

                        AUTHORIZATION AGREEMENT 
                        FOR DIRECT DEPOSIT OF EFT PAYMENTS 

  SECTION 4 
  ƒ Whereby authorize Ohio Office of Budget and Management to initiate credit entries to our account in the financial institution identified above 
    and also debit entries, if necessary, for any credit entries that are determined to be in error. We additionally authorize the financial institution 
    to credit or debit the same to our account. 
  ƒ This authority is to remain in effect until revoked by us in writing to Ohio Shared Services. 

  SIGNATURE:  
                                                                                                  DATE:   
 
OSS USE ONLY: 
         DATE RECEIVED   DATE ENTERED            INITIALS OAKS VENDOR ID NUMBER 

OBM-1234                                                                                                 REV. 8/21/2009

                        AUTHORIZATION AGREEMENT 
                        FOR DIRECT DEPOSIT OF EFT PAYMENTS 

  INSTRUCTIONS FOR COMPLETING THE AUTHORIZATION AGREEMENT FOR DIRECT 
                                       DEPOSIT OF STATE WARRANTS 
 
                                                  SECTION 1 
                                                                
  A.  Place a check-mark to indicate the type of transaction: 
      “Add” indicates a new authorization 
      “Change” indicates a change to an existing authorization 
      “Delete” indicates a request for termination of direct deposit 
 
  B.  Enter the complete name and address of the company or individual participating in the EFT program. 
 
  C.  Enter  your company’s Federal Tax Identification number or  your Social Security number if  you, as an  individual  are 
      participating.  If you are a state employee, please enter your e-code number. 
 
                                          SECTION 2 AND SECTION 3  
 
  A.  Enter the name and address of the financial institution  authorized to conduct transaction.  Complete Section 2 if  you are 
      changing your banking information. 
 
  B.  Place a check-mark to indicate the type of account to which funds are to be deposited.  Enter the financial institution’s Transit 
      Routing/ABA number in the spaces provided.  This is a nine digit number that is shown on your check.  It may also be obtained 
      by contacting your financial institution and requesting its Transit Routing/ABA number. 
 
  C.  Enter the account number to which the EFT Transactions are to be accredited.  If less than 17 characters are needed, begin at 
      the left margin and leave any unused spaces blank.    
 
An e-mail or faxed version of this form is not acceptable as a signature is required.  Forward the signed authorization form along with a 
copy of a voided check for a checking account or “spec sheet” from your financial institution for a savings account to: 
 
                                                  Ohio Shared Services 
                                          ATTN: Vendor Maintenance 
                                       4310 E. Fifth Ave. Columbus, OH  43219 
                                                                
 SUBMIT FORM TO:                                                     QUESTIONS? PLEASE CONTACT: 
                                                                      
 Mail:   Ohio Shared Services                                        Phone:         1 (877) OHIO - SS1 (1-877-644-6771)  
         ATTN: Vendor Maintenance                                                   1 (614) 338-4781 
                   4310 E. Fifth Ave. Columbus, OH 43219             E-mail:        vendor@ohio.gov
                                                                                               
OBM-1234                                                                                                                REV. 8/21/2009