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6 d. <br />N <br />Jti <br />FOR NCDA &CS ONLY: North Carolina Department of agriculture <br />Return Request to: <br />Pam Winstead, Supervisor and Consumer Services <br />Accounts Payable, NCDA &CS <br />1001 Mail Service Center Steve Troxler, Commissioner <br />Raleigh, N.C. 27699 -1001 <br />ELECTRONIC PAYMENT REQUEST FORM <br />Terri S. Overton, <br />Director <br />Budget & Finance <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 will 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 document. <br />Payee Name <br />Federal ID # /Social Security # <br />Bank Name <br />Bank routing number <br />{ ) Checking account # <br />( ) Savings account # <br />o 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 Grant Program you are ;participating in as requested bolow. <br />( } FAX # ( _ _ _ ) _ _ _ - _ _ _ _ OR <br />( } E -mail address <br />Authorized Signature: <br />Title: <br />( ) Phone # <br />Date: <br />(ATTACH A VOID CHECK) <br />PLEASE ' I , TI I ¢, <br />E -mail: Pam.Winstead @ncagr.gov <br />1001 Mail Service Center, Raleigh, N.C. 27699 -1001 a (919) 707 -3030 <br />An Equal Opportunity Affirmative Action Employer <br />Attachment number 3 <br />F -6 Page 142 <br />