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4_ <br />FOR NCDA &CS ONLY: North Carolina Department of Agriculture <br />Return Request to: <br />Accounts Payable, NCDA &CS and C on su mer Services Terri S. Overton, <br />1001 Mail Service Center Director <br />Raleigh, N.C. 27699 -1001 Steve Troxter, C ommission er Budget & Finance <br />ELECTRONIC PAYMENT REQUEST FORM <br />For your convenience and benefit, the State of North Carolina offers payees the opportunity to receive future <br />payments electronically, rather than by check. Your payments wile be deposited into the checking or savings <br />account of your choice. In addition to having the money deposited electronically, you also will be notified of the <br />deposit electronically, either by fax or by e -mail. The fax or e -mail will provide you with all the information that <br />would normally be on your check stub. <br />• ATTACH A VOID CHECK, PRINT THE INFORMATION BELOW and MAIL to your Contract <br />Administrator as identified in your cover contract doc <br />Payee Name C CL kCL lAS lJ- 0Iki'l sj <br />Federal ID # 1 Social Security # (D ` (V <br />Bank Name &nTrusI G1Yl <br />Bank routing number 014 © ()Q 1 Dy <br />( X) Checking account # I o C Q I�q 0 3 Lo g d tv <br />( ) Swings account # <br />• FAX number or e-mail address for payment notification. Place a check mark in front of the method of notification <br />you prefer. Identify the Errant Program you are participating in as requested below. <br />( ) FAX # ( I G} L l ) a 2- 0 - A g R OR <br />{ )(} E -mail address j9 C, 14 (,y % [?c,hai-f`uS C ()()a an ��4. Lc_C_ <br />fA <br />Authorized Signature: r e� � ���'c2.z,c- ��/' -- Date: Y 13 <br />Title: +� 55 15 TL2 n r" ri nct n C.P.. ► f`e 64TIr <br />( ) Phone # ( ) '� 1 - a9 g o f q <br />(ATTACH A VOID CHECK) <br />PLEASE IDENTIFY THE GRANT PROGRAM YOU ARE <br />PARTICIPATING IN: Kc 41)F <br />1001 Mail Service Center, Raleigh, N.C. 27699 -1001 • (919) 707 -3030 <br />An Equal Opportunity Affirmative Action Employer <br />F - 7 <br />Attachment number 2 <br />Page 257 <br />